Patient Information
Uploaded by
smartsportsPatient Information
Uploaded by
smartsportsPatient Information
Patient Name: Last , First , Initial
Patient Address , City , State , Zip Code
E Mail: Cell Home Phone
SSN Sex M F Marital Status M S W D
Employer Employer’s Address
Spouse’s Name Spouse’s Employer
Date of Injury/On Set Date of Birth / /
TYPE OF VISIT: Insurance (Present card at Check-In) Self-Pay (Payment due at time of service)
Workers Compensation We can only file State of Wyoming Work Comp Auto- Accident We CAN NOT file third party
Referring Physician: Address Phone:
Responsible Party If Other Than Self
Name: Relationship:
Address: City: , State: , Zip:
Phone: Phone: SSN:
Emergency Contact: Phone:
Insurance Information
Primary Insurance: Member ID # Group #
Address , City , State , Zip
Policy Holders Name Phone Relationship to Patient
Date of Birth / / Sex: M F SSN
Secondary Insurance: Member ID # Group #
Address , City , State , Zip
Policy Holders Name Phone Relationship to Patient
Date of Birth / / Sex: M F SSN
I authorize medical treatment of the above named person and agree to be financially responsible for all charges for
treatment.
I authorize SMART Sports Medicine Center to release any medical information necessary to process my insurance claims.