BAY AREA NEUROSURGERY, P.A.
813 S. Parsons Avenue
Brandon, FL 33511

PATIENT INFO SHEET
Patient's Name: last first m.i.
Street Address :
City: State: Zip:
Email address:
Home Ph#:     Work Ph#:     Cell#:
Social Security#:   Date of Birth: / /   Age:   Male: Female:
Whom may we thank for referring you today?     Ph #:
Primary Care Doctor:     Ph#:
Employer:     Address:
Spouse/next of kin/notify in case of emergency
Last Name:     First Name:
Relationship:    Ph #:
Insurance Information
Primary Insurance:
Subscriber ID#:     Group#:
Subscriber (If different from patient): DOB: / /
SSN:
Secondary Insurance:
Subscriber (If different from patient): DOB: / /
SSN:
Subscriber ID#:     Group#:
Other Claim: Workman's Compensation Claim: Yes: - No:     Auto Accident: Yes: - No:
Adjustor:     Phone #:     Date of Injury: / /
Claim #:

Authorization and Release:
I authorize the release of any information including the diagnosis and the records of any treatment or examination rendered to me during the period of such care to the third party payers and/or other health practitioners.  I authorize and request my insurance company to pay directly to the doctor or doctor’s group, insurance benefits otherwise payable to me. If payment is made to me, I agree to pay BAN the amount paid to me.  I understand that my insurance carrier may pay less than the contracted rate for services.  I agree to be responsible for payment of all services rendered on my behalf or my dependents at the allowable rate.  If I am not effective on my insurance at the time of service, I agree to pay 100% of the BAN bill rate.
Patient Signature:________________________________________ Date:______________________
Caution: Bay Area Neurosurgery is unable to guarantee the security of information passed via e-mail.