Patient Demographics
name:_________________________________ date of birth:_____________ gender:male female
address:____________________________________ apartment _________________
city:_______________________________________ state: MA NH zip code:________
home phone:___________________________ work phone: ____________________
social security number:_____________________ employer:_____________________
status: single married employed retired Referred by:____________________________
If you would like us to communicate with you over the Internet, please list your email address. Do not list an email address if you are uncomfortable having your personal information on the Internet.email address:_________________________

Primary Insurance: company:_______________________________
subscriber name:_______________________________ relationship to patient: self spouse child other
subscriber social security number:____________________ subscriber date of birth:_____________

Secondary Insurance: company:_______________________________
subscriber name:______________________________ relationship to patient: self spouse child other
subscriber social security number:____________________ subscriber date of birth:____________

1. I agree to make all payments, including copayments, at the time of service.
2. I understand that this office will submit claims to Medicare and selective other insurance companies. I understand, that, when possible, this office will make a single attempt to process claims through to my secondary insurance.
3. I understand that Medicare and insurance companies do not pay for all medical services. I agree to pay all legal claims which are not paid by my insurance company.
4. I agree to assume the responsible for resolving payment problems with my insurance company.
5. I understand that there will be a $25 administration fee added to all returned checks.
6. I have received a copy of this office's Notice of Privacy Practices.
7. I authorize the release of any medical, sensitive or psychiatric information which is necessary to process claims.
8. I authorize my insurance company to make payment for medical benefits directly to this office.

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Print name / Signature / Date

Medicare patients only: Notification to Medicare B patients (does not apply to Secure Horizons)
Medicare will only pay for services that it determines to be "reasonable and necessary" under section 1862(a)(1) of the Medicare law. If Medicare determines that a particular service, although it would otherwise be covered, is "not reasonable and necessary" under Medicare program standards, Medicare will deny payment for that service. It is believed that, in your case, Medicare will deny payment for routine physical examinations, and any testing associated with this exam, and immunizations such as Tetanus injections. Therefore, payment for those services will be expected at the time the service is provided.

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Print name / Signature / Date