Fields marked with an * are required
PATIENT INFORMATION
PLEASE PRESENT ALL INSURANCE CARDS, FORMS, AND ID'S
POLICY HOLDER RESPONSIBLE FOR ACCOUNT ABOVE
PAYMENT IS DUE AT THE TIME OF SERVICE. If we are filing insurance, you will need to pay a portion. This must be done BEFORE services are rendered. ALL ACCOUNTS MUST BE PAID WITHIN 30 DAYS.
PLEASE ANSWER EACH QUESTION
CHECK YES OR NO. HAVE YOU HAD ANY OF THE FOLLOWING?
The above information is accurate and complete to the best of my knowledge and is only for use in my treatment, billing and processing of insurance for benefits for which I am entitled. I will not hold Drs. Strull & Strull, PSC or any member of their staff responsible for any errors or omissions that I may have made in the completion of this form. I consent to the release of information for insurance purposes and authorize the responsible third party to pay directly Drs. Strull & Strull, PSC, insurance benefits due me for services rendered. I also understand that I am responsible for any unpaid balance due Drs. Strull & Strull, PSC, plus any and all costs incurred by Drs. Strull & Strull, PSC including reasonable attorney fees, in the collection of said unpaid balance.
Office use only.
Note: Patient can sign the forms when they come into the office.
