HEAD OF HOUSEHOLD

Name: Date of birth: Telephone

Street Address: Apt: City: State: Zipcode:

Marital Status: Single Married Divorced Widowed Sex: Race:

Employer: Occupation: Social Security #:

Employer’s Address: Work Telephone:

SPOUSE

Name: Date of Birth: Acct #:

Employer: Occupation: Social security #:

Employer Address: Work Telephone:

CHILDREN

Name: Date of Birth:

IN CASE OF EMERGENCY CONTACT:

Name: Relationship: Work Phone: Home Phone:

Referred By: ٱ Physician ٱ Friend/Relative ٱ Telephone Book ٱ Other

Name: Address: Phone:

INSURANCE (Please present current insurance card to receptionist)

Primary Ins. Co: Policy No. Group No.

Claims Processing Address: Telephone

Insured’s Name Relationship to Patient

Employer:

Comments:

Secondary Ins. Co: Policy No. Group No.

Claims Processing Address: Telephone

Insured’s Name Relationship to Patient

Employer:

Comments:

Is this visit due to an employment-related or auto accident? ٱ Yes ٱNo

Date of Injury Nature and Location of Accident

PERMISSION FOR TREATMENT: Permission is hereby granted to George C. Stege, III, M.D., to render such medical and surgical treatment as is deemed necessary.

RELEASE OF INFORMATION: To the extent necessary to determine insurance benefits, liability for payment and to obtain reimbursement, George C. Stege 111, M.D. may disclose portions of the patient’s medical record and account to any person or corporation which is or may be liable for all or any portion of the patient’s charges including but not limited to insurance companies, health care service plans, or worker’s compensation carriers. The patient’s medical record may also be released to the referring physician to ensure continuity of medical care.

FINANCIAL AGREEMENT: In consideration of the services rendered to the patient, the undersigned agrees to accept full financial responsibility for the patient’s account in accordance with the regular rates and terms of the facility. Should the account be referred for collections, the undersigned shall pay reasonable attorney’s fees and collection expenses. Louisville Center for Weight Loss does not participate with any insurance companies and you are responsible for all charges. As a courtesy we will provide you with the information to file an out of network claim.

ASSIGNMENT OF INSURANCE BENEFITS: I request my insurance carrier to pay to George C. Stege, III, M.D. all benefits due me related to my pending claim for medical and surgical services.

MEDICARE S AUTHORIZATION: I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carriers, or to the billing agent of this physician or supplier, any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or to the party who accepts assignment.

I have read and approved all of the above except for those items I have personally lined through and initialed.

Signature of Insured/Guardian Date