BALANCE PATIENT INFORMATION FORM

Office: _______________________________________ Account: ____________________ Date: ____________________
Patient Name: __________________________________________________________ Date of Birth: ________________
Home Address: _____________________________________________________________________________________
City: __________________________________________ State: __________________ Zip Code: ____________________
Home Phone #:__________________________________ Cell Phone #: _____________________________________
Social Security #: ________________________________ Email Address: _______________________________________

Emergency Contact: ______________________________________________________ Relationship: ________________
Home Address: _____________________________________________________________________________________
Home Phone #: _________________________________ Work Phone #: _______________________________________
RESPONSIBLE PARTY
Name: ________________________________________ Address: ____________________________________________
Phone #: _______________________________________ Work #: ____________________________________________
Relationship to Patient: ___________________________________ Date of Birth: ________________________________
EMPLOYMENT INFORMATION
Employer: _____________________________________ Employer Phone #: ____________________________________
Employer Address: __________________________________________________________________________________
MEDICAL INFORMATION
Referring Physician: _____________________________ Address: _____________________________________________
Primary Care Physician: __________________________ Address: _____________________________________________
Primary Diagnosis/Nature of Injury: _________________________ Other Diagnosis: _____________________________
Date of Surgery: ______________________
IF WORK RELATED, PLEASE ANSWER THE FOLLOWING:
Date of Injury: ________________________ Employer at Time of Injury: _______________________________________
Employer Phone #: ____________________ Address: ______________________________________________________
Workers Comp. Insurance Name: _______________________________________________________________________
City: _________________________________________ State: ________________________ Zip Code: _______________
Phone #: ___________________________________________ Extension #: _____________________________________
Adjuster Name: _____________________________________ Claim #: ________________________________________

INSURANCE INFORMATION

Primary Insurance: __________________________________________________________________________________
Address: ___________________________________________________________________________________________
City: __________________________________________ State: ________________________ Zip Code: ______________
Phone #: ______________________________________  Insured SS #: ________________________________________
Policy #: _______________________________________ Group Name/Number: ________________________________
Name of Insured: ________________________________ Date of Birth: ________________________________________
Relationship to Patient: ___________________________

Secondary Insurance: ________________________________________________________________________________
Address: ___________________________________________________________________________________________
City: __________________________________________ State: ________________________ Zip Code: ______________
Phone #: _______________________________________ Insured SS #: ________________________________________
Policy #: _______________________________________ Group Name/Number: ________________________________
Name of Insured: ________________________________ Date of Birth: ________________________________________
Relationship to Patient: ___________________________

Assignment of Benefits / Authority for Release of Information:
I request that payment of authorized Medicare, Medicaid, or private insurance benefits be made to Balance Prosthetics & Orthotics, Inc. for any covered services furnished to me by this facility.  I authorize the release of any information necessary to provide services or process claims.  As the responsible party I understand that I am personally responsible for the entire amount of my claim and that insurance benefits may be limited or non-existent.  I understand that I will be notified of any financial obligation prior to the fabrication/ ordering of my device.  I agree to notify Balance Prosthetics & Orthotics, Inc. immediately of any change in insurance coverage or status.

______________________________________________________       _________________________________________ 
Patient or Responsible Party Signature				           Date

I certify that I have received a copy of Balance’s Notice of Privacy Practices.

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Patient or Responsible Party Signature                                                          Date