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    Alpine Medical Associates Steven M. Brown, M.D.: Signed - Date

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    Sunil Naik
    This document appears to be a new patient intake form for Alpine Medical Associates, a medical practice in Minden, Nevada. The form collects personal information about the patient such as name, address, phone numbers, insurance information, and emergency contact. It also asks whether any current condition or injury is work, auto, or accident related. The patient signs an authorization at the bottom of the form allowing the medical practice to be paid directly for services and to release related medical information for processing claims.

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    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Alpine Medical Associates Steven M. Brown, M.D.: Signed - Date

    Uploaded by

    Sunil Naik
    33 views1 page
    This document appears to be a new patient intake form for Alpine Medical Associates, a medical practice in Minden, Nevada. The form collects personal information about the patient such as name, address, phone numbers, insurance information, and emergency contact. It also asks whether any current condition or injury is work, auto, or accident related. The patient signs an authorization at the bottom of the form allowing the medical practice to be paid directly for services and to release related medical information for processing claims.

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    This document appears to be a new patient intake form for Alpine Medical Associates, a medical practice in Minden, Nevada. The form collects personal information about the patient such as name, address, phone numbers, insurance information, and emergency contact. It also asks whether any current condition or injury is work, auto, or accident related. The patient signs an authorization at the bottom of the form allowing the medical practice to be paid directly for services and to release related medical information for processing claims.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    33 views1 page

    Alpine Medical Associates Steven M. Brown, M.D.: Signed - Date

    Uploaded by

    Sunil Naik
    This document appears to be a new patient intake form for Alpine Medical Associates, a medical practice in Minden, Nevada. The form collects personal information about the patient such as name, address, phone numbers, insurance information, and emergency contact. It also asks whether any current condition or injury is work, auto, or accident related. The patient signs an authorization at the bottom of the form allowing the medical practice to be paid directly for services and to release related medical information for processing claims.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
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    ALPINE MEDICAL ASSOCIATES

    1667 Lucerne Street, Suite A


    Minden, NV, 89423
    Steven M. Brown, M.D.
    Last Name: First Name: M.I. Social Security D.O.B.
    Mailing Address City, State, Zip

    Physical Address City, State, Zip

    Home Phone Work Phone Sex Marital Status

    Employer or School Work/School Phone Work/School Phone City, State, Zip

    Spouse/Parent Last Name First M.I. Date of Birth Sex

    Relationship to Patient Social Security Number Drivers License Number

    Employer Work Phone

    Employer Address City, State, Zip

    In Case of Emergency (not related) Home Work


    Primary Insurance Address City, State, Zip Insurance Phone

    Name of Insured Address City, State, Zip Insured Phone

    ID # Social Security Relationship Insured


    Group # Employer
    Secondary Insurance Address City, State, Zip Insurance Phone

    Name of Insured Address City, State, Zip Insured Phone

    ID# Social Security Relationship to Insured


    Group # Patient Employer

    ACCIDENT OR INJURY INFORMATION


    Accident Accident Injury Workers Auto Slip/Fall Other-
    Y N Date Date Comp Y N Y N Specify
    Y N
    Employment Name of City State Zip
    Related Employer
    Current
    Previous

    AUTHORIZATION TO PAY BENEFITS TO PHYSICIAN: I hereby authorize payment


    directly to the above signed physician for the medical benefits, if any, otherwise payable
    to me for services described. I hereby authorize the above-signed physician to release any
    information necessary to process this claim

    Signed_________________________
    Date______________

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