Consultation Admittance Information
First Name M.I. Last
Nickname Street Address
City, State Zip Social Security #
Female Ā Male Ā 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
My condition is due to: Ā Auto Accident Ā Personal Injury Ā Work Injury Ā Sport Injury Ā other
Type of Claim: Ā Cash Ā Group Insurance Ā Medicare Ā Auto Claim Ā Workerís Compensation
I will be paying by Ā Cash Ā Personal Check Ā Visa/ MasterCard (credit) Ā Visa/MasterCard (debit)
Relationship to Insured Ā Self Ā Spouse Ā Child Ā Other
Insuredís Name Insuredís SS#
Insuredís Birth Date Insurer
Address City State Zip
Policy # Group # Insurer Phone
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.
Patientís Signature Date
Guardianís Signature Date
Crum Chiropractic, 16 Woodlake Drive, Holland, PA 18966