GORDON L GRADO, MD,
INC
PATIENT INFORMATION
SHEET
(Please Print)
Date:_______________________________________________________ □ Glendale * □ Scottsdale * □ Minneapolis
Patient
Name:_______________________________________________________________ SS#______________________________
Last First Middle
Mailing
Address:_____________________________________________________________
Phone ( )______________________
PO Box/Apt or Space # City/Province/State/Zip Cell ( )______________________
Permanent Fax ( )______________________
Address:_____________________________________________________________ Phone ( )______________________
Temporary/Local
Address:_____________________________________________________________ Phone ( )______________________
AT THIS ADDRESS UNTIL (DATE)________________________
Address:______________________________________ Birth Date______ /_____/_____ Age:_______ □ Male □ Female
Month Day Year
Employer:__________________________________________________________ Occupation:___________________________
Address:_____________________________________________________________ Phone ( )______________________
Marital Status: □ Single □
Married □ Separated □ Divorced □ Widowed
Spouse
Name:________________________________________
SS #___________________________
Birth Date:_____/_____/_____
Address:_____________________________________________________________ Phone ( )______________________
Spouses
Employer:__________________________________________________________ Occupation:___________________________
Address:_____________________________________________________________ Phone ( )_______________________
Responsible Party for Payment:__________________________________________ Relationship:_______________________
(NON-INSURANCE)
Address:_____________________________________________________________ Phone ( )_______________________
Emergency Contact:___________________________________________________ Relationship:________________________
Address:_____________________________________________________________ Phone ( )_______________________
Primary Care Physician:________________________________________________ Phone ( )_______________________
Address:_____________________________________________________________ UPIN #:____________________________
Referring Physician:___________________________________________________ Phone ( )_______________________
Address:_____________________________________________________________ UPIN #:____________________________
ADVANCE DIRECTIVES—You have the right to prepare legal documents relating to: #1 your decision to refuse medical treatment you do not want; #2 requesting medical you do want; or #3 your ability to make medical decisions yourself.
Have you prepared any documents relating to the above 3 issues? □ YES □ NO
If yes, please provide a copy of the signed originals of the documents for inclusion in your medical files.
I understand that by proceeding with services I am responsible for payment of this account. The balance due may include deductibles, office visits, co-payments or other services not paid by insurance or other amounts determined to be patient responsibility. In the event of default, I also understand that collection costs and/or attorney fees may be charged to effect collection. Co-payments are due at time of service. Balances are due at time of billing.
Signature:__________________________________________________________ Date:_______________________________
Patient or
Responsible Party
INSURANCE INFORMATION
Please list all insurance coverages which you expect to be filed for payment of services provided to you. If there are more than two insurance companies providing coverage, please request an additional form from our receptionist.
If you change or have changed insurance companies, or you become eligible for another type of coverage during the course of your treatments, please notify one of our staff immediately!
Primary Policyholder__________________________________________
Insurance______________________________________
Relation to Patient_____________________________________
Address________________________________________
Employer_____________________________________________
_______________________________________________ Effective
city/state/Zip Policy ID #_______________________ Date _____/_____/____
Phone ( )___________________________________ Group ID #_______________________ Local #______________
Second Policyholder__________________________________________
Insurance______________________________________
Relation to Patient_____________________________________
Address _______________________________________
Employer_____________________________________________
_______________________________________________ Effective
city/state/Zip Policy ID #______________________ Date _____/_____/____
Phone ( )___________________________________ Group ID #______________________ Local #_______________
Prior Authorization Required? □ YES □ NO Are You Eligible for Medicare? □ YES □ NO
Hospital Coverage Only? □ YES □ NO Do You Have Medicare Part A Only? □ YES □ NO
Applied for AHCCCS/Medicaid? □ YES □ NO Medicare Replacement HMO Policy? □ YES □ NO
AUTHORIZATION & ASSIGNMENT OF BENEFITS
I hereby authorize GORDON L GRADO, MD, INC and/or GRADO BRACHYTHERAPY, PC to furnish information to my insurance carrier(s) concerning my illness and treatments.
I hereby assign payment direct to GORDON L GRADO, MD, INC and/or GRADO BRACHYTHERAPY, PC the surgical and/or medical benefits otherwise payable to me under the terms of my insurance. I understand that I am responsible for any amount not covered by insurance and that balances are due upon receipt of billing,
I hereby authorize photocopies of this form and my signature to be as valid as the original.
Signature:_________________________________________________________ Date:_____________________________
Patient or Responsible Party
MEDICARE SIGNATURE AUTHORIZATION
I request that payment of authorized Medicare benefits be made to me or on my behalf to GORDON L GRADO, MD, INC and/or GRADO BRACHYTHERAPY, PC for any services furnished me. I authorize any holder of medical information about me to release to Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services.
Name:_____________________________________________________________ ID#:_______________________________
Signature:_________________________________________________________ Date:______________________________
Patient or Responsible Party
I authorize the Medicare Claim Administration to release to GORDON L GRADO, MD, INC and/or GRADO BRACHYTHERAPY, PC claim information for services provided to me by the above named provider(s).
Medicare #_____________________________________________ Retired Railroad? □ YES □ NO
Hospital (Plan A)_____ Effective Date:_____/_____/_____ Medical (Plan B)_____ Effective Date:_____/_____/_____