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PLEASE COMPLETE THE CONTRACT FOR SERVICE FIRST

PATIENT INFORMATION

Which Doctor are you wishing to see?

Name:
 Date of Birth:
Address:
 SSN:
City:
State:
        		Zip:
Marital Status:
        		Home Phone:
        		Email:
Sex:
        		Cell Phone:
        		Employer:
Ocupation:
 Address:
Work Phone:
        		Person to contact in case of emergency:
Relationship:
        		Phone:
Give the names of all Doctors you are currently seeing or have seen in the past
(We must have detailed medical history):
Gynecologist:
 Urinary:
Gastrointestinal:
 Ears, Nose, Throat:
Cardiologist:
 Dermatologist:
General Practice:
 Neurologist:
Allergist:
 Eye:
Thyroid:
 Orthopedist:
Other Internist:
How many times have you been in the hospital in the last 5 years and which hospitals were they?
What type of problems do you have?
Who referred you?
What are your medications?
Please list the surgeries you have had

INSURANCE INFORMATION

Primary Insurance:
Address:
City:
State:
        		Zip:
Phone:
        		ID #:
        		GRP #:
Name of Insured:
Deductible:
 Co-Pay:
Secondary Insurance:
Address:
City:
State:
        		Zip:
Phone:
        		ID #:
        		GRP #:
Name of Insured:
Deductible:
 Co-Pay:

Assignment & Release

I AUTHORIZE RELEASE OF ANY INFORMATION CONCERNING MY (OR MY CHILD'S) HEALTH CARE, ADVICE AND TREATMENT PROVIDED FOR THE PURPOSE OF EVALUATING AND ADMINISTERING CLAIMS FOR INSURANCE BENEFITS. I ALSO HEREBY AUTHORIZE PAYMENT OF INSURANCE BENEFITS OTHERWISE PAYABLE TO ME DIRECTLY TO STEPHEN M. BEENE, MD OR KAREN N. BEENE, MD.

I hereby authorize the release of records or copies of such to:

Stephen M. Beene, M.D.
Karen N. Beene, M.D.
1863 Avenue of America
Monroe, LA 71201
(318) 340-6233
Fax: (318) 340-7993