ATLANTIC MEDICAL PHYSICIANSPATIENT INFORMATION SHEETPATIENT NAME:SOCIAL SECURITY #:DATE OF BIRTH:MAILING ADDRESS:EMAIL ADDRESS:HOME PHONE #:CELL/PAGER #:WORK PHONE #:EMPLOYER:EMPLOYER’S FULL ADDRESS:EMPLOYER’S PHONE #:PHARMACY-Location & Phone #://///////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////REASON FOR VISIT – WAS THIS INJURY RELATED TO: (CHECK ONE):AUTO RELATED?
HOME RELATED?

WORK RELATED?

/////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////INSURANCE INFORMATIONCOMPANY NAME:TYPE: (CHECK ONE)MEDICAL / AUTO

WORKERS COMPENSATION/ HOME OWNER’S / OTHERCOMPANY ADDRESS:ID #:GROUP #:

CLAIM #:

Subscriber Name:

Subscriber Date of Birth:

Relation to Subscriber:

COVERAGE EFFECTIVE DATE:DATE OF INJURY://///////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////GUARANTOR INFORMATIONRESPONSIBLE PARTY: (FULL NAME)(FOR MINORS, SPOUSE OR GUARDIAN)RESPONSIBLE PARTY SSN:DATE OF BIRTH:

ADDRESS:TELEPHONE #:EMPLOYER:RELATIONSHIP TO
PATIENT://///////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////IN CASE OF EMERGENCY NOTIFY: NAME, ADDRESS & TELEPHONE #PHYSICIAN(DR.

HOW WERE YOU REFERRED TO OUR OFFICE? (PLEASE CHECK ONE)FRIEND/FAMILY
INSURANCE COMPANYEMPLOYEROTHER)/////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////I give and assign you, Atlantic Medical Physicians, the right to ask, demand and collect and receive payment for my medical bills from such insurer or from suchother sources as may be obligated for payment. I understand that the assignment of these rights by me does not obligate my physician(s) and Atlantic Medical
Physicians to take any action to collect or receive payment from an insurer or other source and I understand that any outstanding balance that my insurance does notcover is my absolute responsibility. This responsibility can only be changed if a prior arrangement was made in writing by Atlantic Medical Physicians,
It is hereby understood that if I falsify any information on this sheet, the balance will then become my full responsibility deemed payable upon demand. It is hereby
understood that I am responsible for all deductibles, co-payments, co-insurance and/or services not covered by my insurance plan at the time such services arerendered. It is hereby understood and agreed that I will be responsible for an administrative charge of 1% per month that may be imposed on my bill for any unpaidbalance beginning thirty (30) days after receipt of services.
It is further understood and agreed that in the event Atlantic Medical Physicians is forced to take legal action to collect any unpaid balance, that I will be responsible
for paying Atlantic Medical Physicians for reasonable attorney fees, costs and interest associated with any and all legal actions as a result of the unpaid balance.
Signed:Date:
Public law in the State of New Jersey mandates that a physician, chiropractor or podiatrist inform his/her patients of any significant financial interest they may have ina healthcare service. Accordingly, we wish to inform you that certain physicians do have financial interests in the following healthcare services to which we could
refer out patients:
Atlantic Medical Physicians
Date:
Parent, Guardian, Insured Authorized Signature____________________________________________________________________________
Witness Signature