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Date: ______________________________
Patient’s Name : _________________________________ Marital Status :____________
Address : ________________________________________ Date of Birth: _____________
City: ____________________________________________ Age : _______ Sex : M F
State: _______ Zip Code : _________-- _______ S.S. #: _____________________
Home Phone : ( ) _____________--__________________________________
Work Phone: ( ) _____________--__________________________________ Ext. _________
Cell Phone: ( ) _____________--__________________________________
Referred By : _____________________ Employed : Y / N Student : Y / N Retired: Y / N
Drivers License Employer: ___________________________
(Please give drivers license to receptionist
to photocopy for your chart at the time of Address: ____________________________
your office visit.)
______________________________--______
Other Address: __________________________ City State Zip Code
(if applicable)
City: _______________________________ State: __________ Zip Code: _________--_______
==================================================================== PRIMARY INSURANCE
INSURANCE COMPANY NAME: ___________________________________________________
Please Present Card at the time of your office visit
Below information is relating to subscriber (insured , not necessarily patient):
CHECK BOX IF SAME AS ABOVE ( )
Relationship to subscriber: ______ self ______ spouse _______ child ______other (pls. explain)
NAME OF SUBSCRIBER: ____________________________________
S.S. # ___________________________ DATE OF BIRTH : ______________________
SUBSCRIBER'S ADDRESS : ____________________________________________________
_________________________________________________ ______________--__________
City State Zip Code
SUBSCRIBER'S EMPLOYER : _______________________________________________________
EMPLOYER’S ADDRESS: CHECK BOX IF SAME AS ABOVE ? _________________________________________________________
__________________________________________________ ______________--___________
City State Zip Code
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SECONDARY INSURANCE ( if applicable)
INSURANCE COMPANY NAME: _________________________________________________
Please Present Card at the time of your office visit
Below information is relating to subscriber (insured , not necessarily patient):
CHECK BOX IF SAME AS ABOVE ( )
Relationship to subscriber: ______ self ______ spouse _______ child ______other (pls. explain)
NAME OF SUBSCRIBER: ____________________________________
HOME # ( ) ________ -- __________________
S.S. # ___________________________ DATE OF BIRTH : ______________________
SUBSCRIBER'S ADDRESS : ____________________________________________________
_________________________________________________ _____________--___________
City State Zip Code
SUBSCRIBER'S EMPLOYER : _______________________________________________________
EMPLOYER’S ADDRESS: _________________________________________________________
___________________________________________________ ____________--___________
City State Zip Code
====================================================================
FAILURE TO CANCEL AN APPOINTMENT WITHIN 24 HOURS OF APPOINTMENT TIME WILL RESULT IN A
$25.00 FEE.
Do you have a Health Care Surrogate? Y / N If yes please furnish a copy for your medical record.
Do you have a living will? Y / N If yes please furnish a copy for your medical record. If you would like literature on Advance Directives please ask your Doctor.
Primary Language Spoken: ( ) English ( ) Spanish ( ) French ( ) Other _______________
E-Mail Address ______________________________________________________
Name of an emergency contact:_________________________________________________________
Phone number ( )_________-- ________________
Relationship ________________________________________________
Payment is required at the time services are rendered.
We accept Visa, Master Card, American Express,Discover, Cash and Personal Checks.
====================================================================
I authorize the physicians and staff of Associated Family Physicians of Boca Raton, P.L. to render medical care to me that they deem necessary. I guarantee payment of any and all charges for services.
________________________________________________________________________________
SIGNATURE OF PATIENT ( if minor guardian's signature is required) DATE SIGNED
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Dr. Mitchell E. Goldstein * Dr. Lynda Altman * Dr. Owen A. Barruw
Dr. Dushyant J. Utamsingh * Debra A. Costantino, A.R.N.P.
Patients: By dating and signing below this will help us coordinate your health care with other health care providers.
I, authorize any Physician, Hospital, Diagnostic Facility, Health Provider, or Insurance Carrier to release any information on my behalf to Associated Family Physicians of Boca Raton, P.L.
________________________________ _____________/__________________
Print Patient’s Name Date of Birth Social Security #
________________________________ ________________________________
Patient’s Signature (Guardian if minor) Date
I, authorize Associated Family Physicians of Boca Raton, P.L. to release any information on my behalf to any Physician, Hospital, Diagnostic Facility, Health Provider, or Insurance Carrier.
________________________________ _____________/__________________
Print Patient’s Name Date of Birth Social Security #
________________________________ ________________________________
Patient’s Signature (Guardian if minor) Date
I, authorize Associated Family Physicians of Boca Raton, P.L., their doctors and employees to release any medical information on my behalf to the following:
(e.g. family members)
________________________________ ______________________________
1. Print Name Relationship
________________________________ ________________________________
2. Print Name Relationship
________________________________ _____________/__________________
Print Patient’s Name Date of Birth Social Security #
________________________________ ________________________________
Patient’s Signature (Guardian if minor) Date
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AUTHORIZATION TO RELEASE MEDICAL INFORMATION
Release information to:
Associated Family Physicians of Boca Raton, P.L.
9910 Sandalfoot Blvd., Suite 1
Boca Raton, FL 33428
561-883-3030
561-852-7611 fax
I hereby authorize you to release medical records and / or any information including the diagnosis of any treatment or examination to include physical or mental conditions including psychiatric, drug, or alcohol treatment rendered to:
Patient: _______________________________________________________
Date of Birth : __________________________________________________
Social Security Number: __________________________________________
Dates of Service from: __________________ To: ____________________
______________________________________________________________
Excluding any information you do not wish to have released: _____________
______________________________________________________________
____________________________________________ _______________
Signature of Patient (Parent or Guardian if minor child) Date
____________________________________________ _______________
Witness Date
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