| CAPITOL ORTHOPAEDICS & REHABILITATION, LLC Neil J. Barkin, MD Stephen J. Rockower, MD Victor A. Wowk, MD Carter W. Mitchell, MD Marc J. Grossman, MD, PC |
| 6000 Executive Blvd., Suite 510 North Bethesda, Maryland 20852 { local: 301.770.7900 } ~ { Nite 301 938.6256 } ~ { fax: 301.770.7904 } Comments or Corrections, contact: WebMaster ~ Please print out this form, fill it out [PLEASE PRINT] & FAX IT TO 301 770 7904 or bring to office. If you fax, please also fax a copy of your insurance card. Thank you. |
Please Print!
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* Last Name . . . . . . .* First Name . . . . . . * Middle . . . . . . . . . .* . . . . . .Sex . . . . . . . . . . . . . . * . . . . .Age
* Last Name . . . . . . .* First Name . . . . . . * Middle . . . . . . . . . .* . . . . . .Sex . . . . . . . . . . . . . . * . . . . .Age
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* Street Address . . . . . . . . . . . . . . . . . . . . . * Apt.# . . . * City . . . . . . . . . . . . . . . * State . . . * Zip . . . . . . . .
* Street Address . . . . . . . . . . . . . . . . . . . . . * Apt.# . . . * City . . . . . . . . . . . . . . . * State . . . * Zip . . . . . . . .
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* Home Phone . . . . . . . . . * SS# . . . . . . . . . . . . . . . . . . . . * Date of Birth . . . . . . . . . . . * . . . . Marital Status
* Home Phone . . . . . . . . . * SS# . . . . . . . . . . . . . . . . . . . . * Date of Birth . . . . . . . . . . . * . . . . Marital Status
________________________________________________________________________________________
* Name of Employer . . . . . . * Occupation . . . . . . . * Work Phone . . . . . * Email. . . . . . . * Cell Phone . . . . . . . . .
* Name of Employer . . . . . . * Occupation . . . . . . . * Work Phone . . . . . * Email. . . . . . . * Cell Phone . . . . . . . . .
_________________________________________________________________________________________
*Name of Relative not living with you. . . . . . . . . . . . *Their Phone . . . . . . . . . . . . .
*Name of Relative not living with you. . . . . . . . . . . . *Their Phone . . . . . . . . . . . . .
Worker's Comp_______________ Auto Accident_______________ Date of Accident_________________
Referred by: _________________________________________________________________________
MEDICAL INSURANCE INFORMATION
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* Primary Company . . . * Identification No. . . . * Group No. . . . * Subscriber / Relationship to Patient
* Primary Company . . . * Identification No. . . . * Group No. . . . * Subscriber / Relationship to Patient
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* Subscriber's Name . . . * Employer . . . . . . . . . . . . . . . . . . . . . . . . * Work Phone # . . . . . . . . . . . . . .
* Subscriber's Name . . . * Employer . . . . . . . . . . . . . . . . . . . . . . . . * Work Phone # . . . . . . . . . . . . . .
____________________________________________________________________________________
** Subscriber's Date of Birth . . . * S.S. #
** Subscriber's Date of Birth . . . * S.S. #
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* Secondary Company . . . * Identification No. . . . * Group No. . . . * Subscriber. . . . / Relationship to Patient
* Secondary Company . . . * Identification No. . . . * Group No. . . . * Subscriber. . . . / Relationship to Patient
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* Subscriber's Name . . . * Employer . . . . . . . . . . . . . . . . . . . . . . . . * Work Phone # . . . . . . . . . . . . . .
* Subscriber's Name . . . * Employer . . . . . . . . . . . . . . . . . . . . . . . . * Work Phone # . . . . . . . . . . . . . .
____________________________________________________________________________________
** Subscriber's Date of Birth . . . * S.S. #
** Subscriber's Date of Birth . . . * S.S. #
MEDICAL INFORMATION
Reason for visit: _____________________________________________ Side affected ____Left ______ Right
If an injury, what was the cause? _____ work _____ auto _____ sports _______________________ other
If auto accident: State it occured in? _____
Family physician ________________________________ Is this a second opinion? _____ Yes _____ No
Allergies to medications __________________________________________________________________
METHOD OF PAYMENT
_____ Cash _____ Check _____ Credit Card
I, _______________________________________, hereby authorize CAPITOL ORTHOPAEDICS & REHABILITATION, LLC or
VICTOR A. WOWK, MD, PC to apply for benefits on my behalf for covered services rendered by Neil Barkin, MD, Stephen J.
Rockower, MD, Victor Wowk, MD or Carter Mitchell, MD or from Marc Grossman, MD, PC from the belowmentioned insurance
company, and promise to pay all outstanding amounts as determined by insurance company. I agree to pay for "No Show" fees
as described by the office. I agree to pay all reasonable interest charges, collection fees and attorney fees in relation to the
collection of these amounts.
VICTOR A. WOWK, MD, PC to apply for benefits on my behalf for covered services rendered by Neil Barkin, MD, Stephen J.
Rockower, MD, Victor Wowk, MD or Carter Mitchell, MD or from Marc Grossman, MD, PC from the belowmentioned insurance
company, and promise to pay all outstanding amounts as determined by insurance company. I agree to pay for "No Show" fees
as described by the office. I agree to pay all reasonable interest charges, collection fees and attorney fees in relation to the
collection of these amounts.
_____________________________________________________________________
( Name of Insurance Carrier)
( Name of Insurance Carrier)
I permit a copy of this authorization to be used in place of the original.
Signature ___________________________________________________ Date __________________________
Signature ___________________________________________________ Date __________________________
I certify that the information I have reported with regard to my insurance coverage is correct, and I authorize the release of any
information, including medical information for this or any related claim to
information, including medical information for this or any related claim to
________________________________________________________________________________________.
( Name of Insurance Carrier)
Signature _______________________________________ Date __________________________
( Name of Insurance Carrier)
Signature _______________________________________ Date __________________________
MEDICARE LIFETIME AUTHORIZATION
"I request that payment of authorized Medicare benefits be made either to me or on my behalf to CAPITOL ORTHOPAEDICS &
REHABILITATION, LLC or MARC J. GROSSMAN, MD, PC for any services furnished me by that physician or supplier. I authorize any holder of
medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these
benefits or the benefits payable for related services. "
Signature _______________________________________ Date __________________________
Medicare I. D. Number _______________________________________
REHABILITATION, LLC or MARC J. GROSSMAN, MD, PC for any services furnished me by that physician or supplier. I authorize any holder of
medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these
benefits or the benefits payable for related services. "
Signature _______________________________________ Date __________________________
Medicare I. D. Number _______________________________________
last edit 10.14.09 sjr
Account # __________________
