Consultation Admittance Information

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First Name M.I.  Last

Nickname Street Address

City, State Zip Social Security #

Female �    Male �    Marital Status   S   M   W D/S    Spouse Name

Birth date    Home phone

Home E-mail  Work/Alternate phone & extension

Fax #  Beeper /Beeper PIN

Cell phone   Work/Alternate E-mail

Emergency Contact Person    Phone

Claim Information

My condition is due to:  �  Auto Accident   �  Personal Injury   �  Work Injury   �  Sport Injury   �  other

Type of Claim:   �  Cash   �  Group Insurance   �  Medicare   �  Auto Claim   �  Worker’s Compensation

I will be paying by   �  Cash   � Personal Check   � Visa/ MasterCard (credit)   �  Visa/MasterCard (debit)

Insurance Information

Relationship to Insured   �  Self   �  Spouse   � Child   �  Other 

Insured’s Name Insured’s SS#

Insured’s Birth Date Insurer

Address  City State  Zip

Policy #  Group #  Insurer Phone

Authorizations

A. I hereby authorize release of any health history information necessary to process this claim and request payment of insurance benefits to Crum Chiropractic in consideration of that office accepting the assignment of such benefits.

B. I authorize payment of any medical benefit from third-parties for benefits submitted for my claim be paid directly to Crum Chiropractic. I authorize the direct payment to Crum Chiropractic any sum I now or hereafter owe this office by my attorney, out of the proceeds of any settlement of my case and by any insurance company contractually obligated to make payment to me or Crum Chiropractic based upon the charges submitted for goods or services rendered.

C. I understand and agree that health and accident policies are an arrangement between an insurance carrier and me. Furthermore, I understand that Crum Chiropractic will prepare any necessary reports and forms to assist me in making collection from the insurer and that any amount authorized to be paid directly to Crum Chiropractic will be credited to my account upon receipt. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for products or professional services rendered will be immediately due and payable.

Patient’s Signature  Date

Guardian’s Signature Date

Crum Chiropractic, 16 Woodlake Drive, Holland, PA 18966