Welcome to Respiratory Disease Associates and Lung Diagnostics
Please Print
Date:_____________________
Home Phone:__________________ Cell Phone: __________________
Patient Name:____________________________________________________________
Responsible Party __________________Relationship________________
Address:________________________________________________________________
City:_____________________________ State: ______________ Zip Code:__________
Email Address: ________________________________
Sex: Male__ Female__
Age ______ Birthdate ________ Marital Status: _____ Are you still working? ______
Social Security #____________________ Local Pharmacy Name/Address: _________________________
Mail Order Pharmacy: ________________________________
Patient Employed by ____________________________________________________________________
Patient’s
Business Address:______________________________________________________________________
Past or Present Occupation:_______________________________________ Business Phone:____________
Spouse (or responsible party) Name: __________________________________________DOB: ___________
Spouse or responsible party
Business Name and Address: _______________________________________________________________
Insurance Information: Medicare Number:______________________ is Medicare your primary? __________
Other Insurance Name and ID# ____________________________________________________________
Managed Care Provider:_______________________ ID# ____________________ Do you require a referral? ____
Who is your primary care physician? _________________________________ Phone #__________________
Who referred you to our office?____________________________________Phone#__________________
Have your insurance card and driver’s license ready so we can make copies.
Emergency Contact: __________________________ Relationship: _________Phone # _________________
Beneficiary Statement:
I, the undersigned certify that I (or my dependent) have insurance coverage with the company listed above. I understand that I am financially
responsible for copayments, deductibles, or any balances after insurance as outlined in the explanation of benefits.
I request that payment of authorized Medicare benefits and all third party insurance carriers, be made either to me or on my behalf
To; Respiratory Disease Associates for any services furnished me by this facility. I authorize any holder of medical information about me be
released to the Health Care Finance Administration and it’s agents or any other insurance company, information needed to determine these
benefits payable for the related services rendered.
Authorized Signature:______________________________________________________ Date:__________________________