Foot & Ankle Clinic of Central Nebraska
620 N Diers Ave Suite 100 PO Box 5020
Grand Island NE 68802
Phone: 308-381-0404 Fax: 308-381-0408 Toll Free: 1-800-847-6544
Kevin J. Larsen DPM Jonathan B. Wilson DPM Amanda L. Walsh DPM
Date: ___________ Patient: ______________________________________________________________________
(First Name) (Middle Initial) (Last Name)
Social Security # _______________________ Date of Birth: _____________________ Age: ____________
Gender: Male Female Nickname: ___________
Home Address: _________________________________________________________________________________
(Street and PO Box) (City) (State) (Zip Code)
Home Phone: _____________________ Cell Phone: ______________________ Work Phone: _________________
Mailing Address: ________________________________________________________________________________
(PO Box) (City) (State) (Zip Code)
Please Circle: Married Single Widow Divorced
Parent Name if patient is under 18: __________________________________ Parent Birthdate:__________________
Patient Employer: ___________________________________________________ Work Phone: __________________
Patient Driver’s License # ______________________ Patient Pharmacy: _________________________________
INSURANCE INFORMATION:
Policy Holder’s Name:____________________________________ Birthdate:_____________ SS#:_______________
Who can we thank for this referral: __________________________________________________
Is this Workman’s compensation related? Yes No
Authorization of Benefits
I authorize the release of any medical information necessary to process this claim. I authorize payment of medical benefits to Foot and Ankle Clinic of Central Nebraska for the services described on the claim form submitted.
Patient Signature _________________________________________________________________
Medicare Signature on File and Medigap Assignment of Benefits
I request that payment of authorized Medicare benefits to Foot & Ankle Clinic of Central Nebraska for any services furnished me by that Physician. 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 to related services. I hereby authorize payment of my Medigap benefits to this provider for all claims filed on my behalf. This authorization applies to all services until it is revoked by me or my representative. I understand my signature below requests that payment be made and authorizes release of medical information necessary to pay the claim. If other health insurance is indicated in item 9 of the HCFA-1500 form, or elsewhere on other approved claims or electronically submitted claims my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the provider agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, co-payment and non-covered services. Co-insurance and the deductible are based upon the charge determination of the Medicare carrier.
Patient Signature _____________________________________________________ Date _____________
Tags: ankle clinic, & ankle, nebraska, ankle, central, clinic