Please complete this form using your keyboard, then print it using the print function of your browser.  You can then sign the form and bring it with you to your first appointment. This form will not be submitted via the Internet, so security is not an issue.

The following questions are necessary so that we may properly file your insurance for you.  These questions are taken directly from the insurance form that we must fill out and file for you.  Please answer as fully as possible.

1.  Type of insurance:  Medicare    Medicaid    Champus    CampVA   

    Group Health Plan    Other    Insured's ID Number

2.  Patient Name: 

3.  Insured's Name (as it appears on the insurance card):

4.  Patient's Address:

    City     State     Zip     Phone

5.  Insured's Address (if same as patient put "same") 

    City     State     Zip     Phone

6.  Patient Status (check one): Single Married Other Employed Full-time Student Part-time Student

7.  Other Insured's Name (if applicable):

    Other Insured's Policy or Group Number:

    Other Insured's Date of Birth         Male         Female

    Employer's Name or School Name: 

    Insurance Plan Name or Program Name:

8.  Is the condition we are treating related to current or previous employment?  Yes    No

9.  Is the condition we are treating related to an auto accident?  Yes    No

10.  Is the condition we are treating related to another type of accident?  Yes    No

11.  Insured's Policy Group or FECA Number: 

    Insured's Date of Birth:              Male         Female

    Employer Name or School Name: 

    Insurance Plan Name or Program Name: 

12.  Is there another health benefit plan?  Yes    No        If yes, list:

Patient's or Authorized Person's Signature:  I authorize the release of any medical or other information necessary to process my insurance claim.  This is to serve as a long-term authorization card.

Signed:  __________________________________    Date:  _________________

Insured's or Authorized Person's Signature:  I authorize payment of medical benefits to Back & Neck Pain Center for the services described on the insurance form.  This authorization is to apply to all occasions of service until it is revoked in writing.  I agree to pay for services not covered by insurance and understand that I am ultimately responsible for payment in full at this office.

Signed:  __________________________________    Date:  _________________

Medicare Only

All doctors have been instructed to ask the following questions of all Medicare patients.

1. Do you or your spouse work for a company that provides you with health insurance? Yes    No

2. Are you entitled to Medicare because of End Stage Renal Disease? Yes    No

3. Is the illness or injury the result of an accident or illness that occurred at work? Yes     No

4. Is this illness or injury the result of an accident or other injury? Yes    No

5. Has the treatment for this accident or illness been authorized by the Veteran's Administration? Yes  No

6. Are you entitled to any benefits under the Federal Black Lung Program? Yes    No

7. Do you have a Medicare Medigap Policy? Yes  No    Name of Company

8. Do you have a Medicare Supplement Policy? (Policy provided by employer you retired from)? Yes   No