New Patients Form -- Stowe Cardiology

Date:________

Patient's name (please PRINT)	SS#	Marital Status					Sex		Birth Date	Age	Religion (optional)
		S	M	W	D	Sep	M	F
Street Address (say if temporary) .	City and state								Zip code
Patient's or parent's employer .	Occupation (indicate if student)						How long employed?			Bus phone # and ext
Employer's street address .	City and state>									Zip code
Drug allergies if any .
Spouse or parent's name .	SS#						Birth date
Spouse or parent's employer .	Occupation						How long employed?			Bus phone # and ext
Employer's street address .	City and state								Zip code
Spouse's address if divorced or separated .	City and state						Zip code			Home phone #
PLEASE READ:	All charges are due at the time of services. If hospitalization is indicated the patient is responsible for furnishing insurance claim forms to the office prior to hospitalization.
Person responsible for payment, if not above .	Street Address, City, State								Zip code	Home phone #
Blue Shield (give name of policyholder) .	Effective date	Certificate #							Group #	Coverage code
Other (write in name of insurance company) .	Effective date								Policy #
Other (write in name of insurance company) .	Effective date								Policy #
Medicare # .	Railroad retirement #		_ Visa _ MasterCard #								Expiry date
Medicaid .	Effective date		Program #				County #			Case #	Account #
Industrial .	Were you injured on the job (yes/no)						Date of Injury			Industrial claim #
Accident .	Was an automobile involved? (yes/no)						Date of accident			Name of attorney
Were X-rays taken of this injury or problem? .	If yes, where were the X-rays taken (hospital etc.)									Date X-rays taken
Has any member of your family been treated by our physicians before? Include name of physician and family member. .
Referred by: .	Street address, city and state								Zip code	Phone #

ALL PROFESSIONAL SERVICES RENDERED ARE CHARGED TO THE PATIENT. NECESSARY FORMS WILL BE COMPLETED TO HELP EXPEDITE INSURANCE CARRIER PAYMENTS. HOWEVER, THE PATIENT IS RESPONSIBLE FOR ALL FEES, REGARDLESS OF INSURANCE COVERAGE. IT IS ALSO CUSTOMARY TO PAY FOR SERVICES WHEN RENDERED UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE IN ADVANCE WITH OUR OFFICE BOOKKEEPER.
INSURANCE AUTHORIZATION AND STATEMENT
Name of Policyholder:___________________________________	HIO Number:_____________
I request that payment of authorized Medicare/Other insurance benefits be made either to me or on my behalf to Stowe Cardiology, or any services furnished me by that party who accepts assignment/physician. Regulations pertaining to Medicare assignment of benefits apply. I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carriers any information needed for this or a related Medicare claim/other insurance coverage claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or to the party who accepts assignment. I understand that it is mandatory to notify the health care provider of any other party who may be responsible for paying for my treatment. (Section 1128B of the Social Security Act and 31 USC 3801-3812 provides penalties for withholding this information).

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address	phone	To Reach Us	Today is:

Stowe Cardiology 377 Cross Road	802.253.2922	Contact Dr. Daum
Stowe, VT 05672