EFTA00314094.pdf

Date: T A rj • I 1)a-IDI CI MITCHELL A KLINE E PATIENT REGISTRATION NAME: J e SOCIAL SECURITY: -53 DATE OF BIRTH1- 2O GENDER 1.\-4 PREFERRED LANGUAGE: I; ICI ‘L1SH Marital Status:eM D W AMERICAN INDIAN OR ALASKA NATIVE ASIAN BLACK OR AFRICAN AMERICAN NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER ETHNIC GROUP: HISPANIC OR LATINO NOT HISPANIC OR LATINO UNKNOWN ADDRESS: ei CAST ST CITY: NI aVV Nh3114-... HomFis ,41 o tqr CELL# a I a - 53R _ 3-4-39 PHARMACY NAME VI TA t4 EA cm PHONE#_I STATE: N y ZIP CODE local WORK# - c at) -q C4 E-MAIL jetAtaCartionaOyncial.C.Din ADDRESS 1,a1S-- `ST Ave • FAX* ( e OCCUPATION/EMPLOYER: ZE2iarar. /4 -71z etcYr CAO. REFERRED BY: (PHYSICIAN, PATIENT, FRIEND, OR OTHER) PLEASE CIRCLE AND LIST NAME: SPOUSE/PARENT: FINANCIAL/INSURANCE INFORMATION Pr Kline does not narticipate with am health insurance. I understand that I am responsible for all chargers incurred and that payment is due at the time services are rendered. We require a copy of your insurance card for laboratory purposes only. I request that payment of authorized Medicare benefits be made either to me or on my behalf to Mitchell Kline. M.D. for semices furnished to me by the provider. I authorize any holder of medical information about me to release to CMS and its agents any information needed to be determine these benefits payable for relatrrl sen ler% CARRIER NAME: LI $ 1-th I-I-GAL-TVCAIZE.7 ID# GROUP ( O OS Employer Sponsored? Government Sponsored? — RELATIONSHIP TO INSURED NAME: S ei% KINDLY GIVE 211IR HOURS NOTICE TO CANCEL APPOINTMENTS. A FEE OF SI00.00 WILL BE BILLED TO YOU FOR LESS THAN 24HOUR HOURS NOTICE AS WELL AS FAILURE TO KEEP SCHEDULED APPOINTMENTS. EFTA00314094