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

(Nazwisko) (Imię) (Kobieta/Mężczyzna)

Address: ________________________________ City: _____________ State: _______

(Adres) (Miasto) (Stan)

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

(Data Urodzenia) (Wiek) (Numer Social Security)

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

(Numer Telefonu) (Stan Małżeński)

Responsible Party: __________________________ Relationship: __________________

(Osoba Odpowiedzialna) (Pokrewieństwo)

Responsible Party: __________________________ Relationship: __________________

(Osoba Odpowiedzialna) (Pokrewieństwo)

Address if different: ______________________________ Phone: __________________

(Adres jeżeli inny) (Telefon)

Employer: _________________________________ Work Phone: __________________

(Miejsce pracy) (Telefon do pracy)

Address: __________________________________ City: ______________ State: _____

(Adres) (Miasto) (Stan)

Zip: ___________ Emergency Contact: ______________________________________

(Kontakt w razie wypadku)

Relationship: ____________________ Phone: __________________________________

(Pokrewieństwo) (Numer Telefonu)

How did you learn of our practice?___________________________________________

(Jak się Pan/Pani dowiedziała o naszej klinice?)

Primary Insurance:______________________________________ Co-Pay: _________

(Ubezpieczenie)

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

(Nazwisko osoby do której należy ubezpieczenie) (Social Security) (Data urodzenia)

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.