___ New Patient   ___ Established Patient     Date: _________ 

Healthcare Provider__________________________________

Last Name: ________________________  First Name: _______________   M.I.: _____
Mailing
Address:   _____________________ City: _______________  State:  _____  Zip: _______  
Street Address if
Different: ______________________  City: _______________  State:  _____  Zip: _______   
Date of Birth: ___/___/___   Sex: M    F   S.S.#:______________Race:_________________
Home Phone: ______________ Work Phone: ________  Other Phone: ________________
Drivers License Number: ___________________________________  State: ___________  
E-Mail Address: _____________Have you provided us a copy of a Living Will?  ___ Y   ___ N
Marital Status: ___ Married  ___ Single  ___ Divorced  ___ Widow   Employed:  ___ Y   ___ N
Employer Name & Address: _______________________________________________________________________

Primary Insurance: _________________     Secondary Insurance: ___________________
Address:_________________________      Address: ___________________________
                _________________________                       ___________________________
Group No.:  _________________________ Group No.:   _________________________
Effective Date: _____________________    Effective Date: _______________________
Insured I.D. No.: ______________________Insured I.D. No.: ________________________
Co-Pay: $______    Deductible: $______      Co-Pay: $__________    Deductible: ________
Insured's Name: _______________ ______ Insured's Name: ________________________
Relationship to Patient: ________________ Relationship to Patient: ___________________
Insured's S.S. #: ___________DOB: ______Insured's S.S. #: ____________  DOB:_______
Insured's Address: ____________________Insured's Address:_________________
___________________________________                                _________________
Insured's Employer: ___________________Insured's Employer: ________________

Last Name: _____________________First Name: ________________________ M.I.: ____
Address:    _________________________City: ___________ State:  ______   Zip:_______

Insurance Company: __________________________ Claim No.:___________________
Insurance Address: ___________________________  Phone No.: __________________
If Worker's Compensation, Name and Address of Employer at time of injury:
______________________________________________________________________  
Date of Injury: __________   Contact Name: ______________Phone No.:_____________  

I hereby authorize my Healthcare Provider and the Centennial Medical Group, P.A. to retain all of my medical records / information in an electronic format.  These records will be maintained in a secured, confidential manner and shall be in compliance with HIPAA Regulations for patient confidentiality.  These records shall not be released without consent of the patient or legal guardian.   This authorization remains in effect until revoked in writing.

Signature: _______________________________________    Date: _______________

I hereby authorize my Healthcare Provider to furnish information to the insurance carrier (s) regarding my treatments.  This authorization remains in effect until revoked in writing.

Signature: _________________________________________    Date: ______________

I hereby assign, to my Healthcare Provider, all payments for medical services rendered to myself or my dependents until revoked in writing.  I understand that I am responsible for any amount not covered by my insurance at the time of service to include co-pays, deductibles and non-covered services.  I also understand that if I do not fulfill my payment obligations to Centennial Medical Group, P.A. my account will be subject to a full collections process.  Any expenses related to the cost of collections and / or legal proceedings will be my responsibility.

      Signature: __________________________________       Date: _______________