Name: Last: ________________________ First: ______________________ Sex: M/F

Address: ________________________________ City: _____________ State: _______

Zip: ___________ Date of Birth: ____________ Age: ______ SS#: ________________

Phone Number: ________________________ Marital Status: Sgl Mar Div Sep Wid

Responsible Party: __________________________ Relationship: __________________

Responsible Party: __________________________ Relationship: __________________

Address if different: ______________________________ Phone: __________________

Employer: _________________________________ Work Phone: __________________

Address: __________________________________ City: ______________ State: _____

Zip: ___________ Emergency Contact: ______________________________________

Relationship: ____________________ Phone: __________________________________

How did you learn of our practice?___________________________________________

Primary Insurance:______________________________________ Co-Pay: _________

Subscriber's Name: ________________________ SS#: _______________ DOB: ______

Group#: ___________________________ Policy#: ______________________________

INSURANCE AUTHORIZATION & ASSIGNMENT

The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize NORTH-WEST CARDIO-VASCULAR CENTER or insurance company to release any information required to process my claims. I have received a copy of the patient privacy rights. This also authorizes you to give me medical treatment demeaned necessary by my physician.