Download date_____________ patient information

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3333 Brookview Hills Blvd., Suite 104
Winston Salem, NC 27103
Telephone: (336) 760-3007
Fax: (336) 760-9334
Edward G. Hill, Jr., MD, Dr.rer.nat.
Andreas D. Runheim, MD
John Robbins, PA-C
Jane Langfitt, PA-C
Sehr Hafiz, PA-C
Unique Robinson, MMS, PA-C
This form is intended to provide medical insurance information to Salem Neurological Center
since my insurance cards are not available to copy at this time. This information is provided so
that Salem Neurological Center can file for payment of charges incurred by me or my dependent.
I understand that if enough information is not provided, my insurance carrier could deny my claim.
I will then be sent a bill for charges incurred until sufficient information is provided. I will make
every effort to supply copies of my card(s) to Salem Neurological Center as soon as possible.
___________________________________
Signature of Patient / Insured
____________________
Date
PRIMARY INSURANCE COMPANY
Insurance Plan or Program Name ________________________________________
Insured/Policyholder’s Name __________________________________Your relationship to Insured _______________________
Insured Address ____________________________________________
City _________________________________
Insured’s date of birth _________________
State _________
Zip ___________
Insured’s sex ________
Certificate or ID # _____________________________________
Insured’s home phone # _____________________
Insured’s social security # ______________________
Group # _______________________________________
Insured’s employer or school __________________________________ Employer or school phone # _____________________
Mail claim form to ________________________________________________________________________________________
SECONDARY INSURANCE COMPANY
Insurance Plan or Program Name ________________________________________
Insured/Policyholder’s Name __________________________________Your relationship to Insured _______________________
Insured Address ____________________________________________
City _________________________________
Insured’s date of birth _________________
State _________
Zip ___________
Insured’s sex ________
Certificate or ID # _____________________________________
Insured’s home phone # _____________________
Insured’s social security # ______________________
Group # _______________________________________
Insured’s employer or school __________________________________ Employer or school phone # _____________________
Mail claim form to ________________________________________________________________________________________