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    PATIENT REGISTRATION

    		  
     
    		 
      INSURANCE AUTHORIZATION AND ASSIGNMENT (Please read and sign below)  
         
     

    FILING INSURANCE CLAIMS IS A SERVICE PROVIDED TO ME WITHOUT CHARGE AND IN NO WAY RELIEVES ME OF MY RESPONSIBILITY FOR MY BILL.

    AUTHORIZATION TO RELEASE MEDICAL INFORMATION: I authorize the release of any and all medical information necessary and required by my insurance company. This release will remain in effect until revoked by me in writing. A photocopy of this release is to be considered as valid as the original.

    ASSIGNMENT OF BENEFITS: I hereby assign, transfer, and set over to Midlands Anesthesiology all of my rights, title and interest to my medical reimbursement benefits under my insurance company. This assignment will remain in effect until revoked by me in writing. A photocopy of this release is considered to be as valid as an original. This Assignment of Benefits clause does apply to active duty military personnel.

    THANK YOU, AND WELCOME TO OUR PRACTICE.

    		  
     
    SIGNATURE : *
       
    Patient First Name: *
    Patient Last Name: *
    Marital Status: *
    Age: *
    Sex: *
    SSN: *
    Street Address: *
    City and State: *
    Postal Code: *
    Home Phone: *
    Patient's Employer (School if Student): *
    Occupation: *
    Business Phone:
    Employer's Street Address:
    City and State:
    Postal Code:
    Guarantor's First Name: *
    Guarantor's Last Name: *
    Guarantor's Date of Birth: *
    Guarantor's Street Address: *
    City and State: *
    Postal Code: *
    INSURANCE INFORMATION:  
    Name of Primary Insurance Company:
    Effective Date:
    Contract #:
    Group #:
    Policy ID# or SSN:
    Address of Insurance Company:
    Insurance Company Phone Number:
    Name of Policy Holder:
    Policy Holders Date of Birth:
    Relationship to Policy Holder:
    Name of Secondary Insurance Company:
    Effective Date:
    Contract #:
    Group #:
    Policy ID# or SSN:
    Address of Insurance Company:
    Insurance Company Phone Number:
    Name of Policy Holder:
    Policy Holders Date of Birth:
    Relationship to Policy Holder:
       
    Please make sure all required fields are completed before submitting your form.
     
       
    		 
     


    If you have any questions please contact us:

    Midlands Anesthesiology
    Attn: Billing Department
    PO Box 1427
    Columbia, SC 29202

    Phone: 866-399-6322

    MA@patient-billing.com

    		  
     

     

     

     

     

     

     
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