REGISTRATION INFORMATION:

Name
Your Email
Social Security Number
Home Phone: (Please include area code.)
Address
City
Zip
Age
Date of Birth Example: MM/DD/YY
Sex
Employer
Occupation
Employer Phone: (Please include area code.)
Referring Physician
Name of a relative or friend (not living with you)
Phone: (Please include area code.)
GUARANTOR DATA:
Name
Relationship
Social Security Number
Sex
Date of Birth
Address
Phone (Please include area code.)
City
Zip
Employer
INSURANCE INFORMATION
Name of Policy Holder
Policy Number
Group Number
Effective Dates
Secondary Policy Number
Group Number
Effective Dates
REFERRAL DATA
Primary Care Physician
Referral Number
Number of Visits
Valid Dates
Diagnosis
Description of Difficulty (indicate right or left)
Case Number
Accident Related?
Date of Injury
How Did the Injury Occur?
Do you have an attorney for the case?
Method of Payment

You and you alone are responsible for your bill. Payment is due when services are rendered unless other arrangements have been made. Your account is between you and the doctor. If insurance payment is pending you are responsibe for payment of your account in full in a timely fashion. When your insurance payment is received, it will be reimbursed to you immediately. Unpaid accounts over one month old are considered deliquent even if insurance payments are pending.

For our patients with Medi-Cal coverage, you must have a current Medi-Cal card with you at the time of the visit. Medi-Cal coverage is accepted only for those patients referred by another physician. If in the course of treatment, Medi-Cal coverage is obtained, retroactive charges will not be accepted and you will be respobsible for all charges up to the point at which we have been informed of your changes in payment status.

This office is contracted with numerous health plans, each of which have different requirements. It is the patient's responsibility to check to make certain that Dr. Levy is a member of their health plan. Failure to do so could make you personally responsible for any or all fees.

Also, many health plans require specific referrals that need to be obtained prior to seeing Dr. Levy. In many instances it is the patient's responsibility and not the responsibility of this office to make certain that these referrals have been completed properly. Failure to do so could result in you being personally responsible for any charges incurred in this office.

Many health plans require a second opinion to be performed by a different physician prior to surgery. It is the patient's responsibility to check with his or her health plan to determine if such a requirement is necessary. Failure to do so could result in this office having to cancel the surgery intil the second opinion has been obtained or it could result in you being personally responsible for any charges incurred.

I hereby authorize Louis J. Levy, M.D., to release information to insurance company or to another physician:

I hereby assign to Louis J. Levy, M.D., all benefits provided by my insurance policy for medical/surgical care, but not to exceed the charges stated for such services rendered. I understand that I am financially responsible fo charges not covered by insurance.

DATE: