TODAY'S DATE:_________________________

PATIENT NAME:_________________________ DATE OF BIRTH:_________

PATIENT ADDRESS:______________________________________________

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HOME PHONE NUMBER:______________________________
(INCLUDE AREA CODE)

EMPLOYER NAME:______________

WORK PHONE NUMBER:____________

SOCIAL SECURITY NUMBER:___________ GENDER: MALE____ FEMALE____

MARITAL STATUS: SINGLE___ MARRIED___ SEPARATED___ DIVORCED___

INSURANCE INFORMATION:
*PLEASE NOTE, IF YOU ARE UNABLE TO PROVIDE US WITH A COPY OF YOUR INSURANCE CARD(S), ALL BILLS WILL BE SENT DIRECTLY TO YOU*

PRIMARY INSURANCE:___________________________________________

SECONDARY INSURANCE:_________________________________________

SUBSCRIBER NAME:_____________________________________________

SUBSCRIBER BIRTHDATE:________ SUBSCRIBER SOC. SEC. #_________

YOUR RELATIONSHIP TO SUBSCRIBER:_____________________________

I AUTHORIZE PAYMENT OF BENEFITS AS DETERMINED BY MY INSURANCE COMPANY TO BE MADE DIRECTLY TO DR. WAYNE B. GLAZIER.

X____________________________________________________________

I AUTHORIZE MY INSURANCE COMPANY AND MY DOCTOR TO RELEASE INFORMATION TO ONE ANOTHER IN ORDER TO PROCESS MY CLAIM. I CERTIFY THAT ALL INFORMATION I HAVE PROVIDED IS TRUE AND CORRECT AND THAT I KNOW IT IS A CRIME TO FILL OUT THIS FORM WITH FACTS THAT I KNOW ARE FALSE OR TO LEAVE OUT FACTS THAT I KNOW ARE IMPORTANT TO THE PROCESSING OF MY CLAIM.

X____________________________________________________________
(IF PATIENT IS A MINOR, GUARDIAN MUST SIGN ABOVE AND LIST RELATIONSHIP TO THE PATIENT)