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The Women's Clinic
Patient Information Record

Date___________________ Chart No.___________

NAME________________________________________________SOCIAL SECURITY #____________________________

DATE OF BIRTH_________________________ SEX_____________ MARITAL STATUS___________________________

ADDRESS___________________________________________________________________________________________

CITY________________________________________________STATE______________________ZIP________________

PHONE: Home___________________________________________Work________________________________________

EMPLOYER__________________________________________________________________________________________

RELIGION____________________________SPOUSE'S NAME_______________________________________________

PERSON RESPONSIBLE FOR PAYMENT

NAME_______________________________________ADDRESS________________________________________________
CITY________________________________________STATE___________________________ZIP____________________
PHONE: Home________________________________Work____________________________________________________
SOCIAL SECURITY #__________________________EMPLOYER______________________________________________
EMPLOYER'S ADDRESS________________________________________________________________________________

INSURANCE INFORMATION

1. INSURANCE CO. 2. INSURANCE CO.
CONTRACT OR POL.# CONTRACT OR POL.#
GROUP # GROUP#
NAME OF SUBSCRIBER NAME OF SUBSCRIBER
RELATION TO PATIENT RELATION TO PATIENT

ASSIGNMENT AUTHORIZATION

I hereby authorize Dr.________________to release to your company representative, any information including the diagnosis and records of any treatment or examination rendered to me during the period of such Medical or Surgical care.
I authorize and request your company to pay directly to the doctor the amount due me in my pending claim for Medical or Surgical treatment or services, by reason of such treatment or services rendered to me a photographic copy of this authorization shall be as valid as the original.

Date:_________________Signature of Patient/Insured___________________________________________________

FRIEND OR RELATIVE NOT LIVING WITH YOU

NAME_________________________________________________________________________________________________
ADDRESS______________________________________________________________________________________________
RELATIONSHIP___________________________________PHONE_______________________________________________
REFERRED BY__________________________________________________________________________________________