Patient Information Form PDF - Aurora Gonzalez, MD and Associates

Aurora Gonzalez, M.D. and Associates
O B S T E T R I C S
Aurora Gonzalez, M.D.
A N D
G Y N E C O L O G Y
Alvaro I. Montealegre, M.D.
PATIENT INFORMATION
DATE/FECHA_________________________SS#_________________________D.O.B./FECHA DE NACIEMIENTO__________________________
NAME/NOMBRE______________________________________________________________________________SEX/SEXO_____________________
ADDRESS/DIRECCION______________________________________________CITY/CIUDAD_______________ZIP /CODIGO________________
HOME PHONE/TELEFONO DE CASA_______________________WORK/TRABAJO_______________________CELL______________________
EMPLOYER/EMPLEADOR___________________________________________________________________________________________________
MARITAL STATUS/ESTADO CIVIL_________________RACE/RAZA_______________DRIVER LICENSE/LICENSIA____________________
SPOUSE/NOMBRE DE ESPOSO________________________________________WORK PHONE/TELEFONO DE TRABAJO________________
EMERGENCY CONTACT/CONTACTO DE EMERGENCIA_______________________________________________________________________
TELEPHONE/TELEFONO______________________________________RELATIONSHIP/RELACION____________________________________
OTHER CONTACT/OTRO CONTACTO________________________________________________________________________________________
TELEPHONE/TELEFONO______________________________________RELATIONSHIP/RELACION____________________________________
INSURANCE INFORMATION/INFORMACION DE SEGURO
INSURANCE COMPANY/NOMBRE DE SEGURO________________________________________________________________________________
NAME OF INSURED/NOMBRE DEL ASEGURADO______________________________________________________________________________
RELATIONSHIP TO PATIENT/RELACION AL PACIENTE_______________________________________________________________________
MEMBER I.D./NUMERO DE POLIZA___________________________________GROUP#/NUMERO DE GRUPO___________________________
SS#OF INSURED/SS# DEL ASEGURADO______________________________D.O.B./FECHA DE NACIEMIENTO_________________________
INSURED EMPLOYER/EMPLEADOR DE ASEGURADO_________________________________________________________________________
OTHER INSURANCE/OTRO SEGURO MEDICO_________________________________________________________________________________
WHO REFERRED YOU/QUIEN LA REFERIO___________________________________________________________________________________
PHARMACY AND #/NOMBRE Y NUMERO DE FARMACIA______________________________________________________________________
I HEREBY AUTHORIZE PAYMENTS OF BENEFITS
TO THE PHYSICIAN WHOSE NAME APPEARS ON THIS
STATEMENT FOR SERVICES RENDERED IN PERSON
OR UNDER THEIR SUPERVISION. I UNDERSTAND
THAT I AM FINANCIALLY RESPONSIBLE FOR ANY
BALANCE NOT COVERED BY MY INSURANCE.
X__________________________
I HEREBY AUTHORIZE THE PHYSICIANS WHOSE
NAMES APPEAR ON THIS STATEMENT TO RELEASE
ANY INFORMATION ACQUIRED IN THE COURSE OF
EXAMINATION OR TREATMENT AND ALLOW A
PHOTOCOPY OF MY SIGNATURE FOR INSURANCE
PURPOSE ONLY.
X__________________________
6410 FANNIN, SUITE 1200, HOUSTON, T X 77030
PHONE: 7137579905
FAX: 7137577952