Billing Information

The following form requests information that will be used for billing purposes. Please complete the form below. Filling out this form electronically will be most efficient. If you prefer to use a Word document please send or bring the electronic file if possible. This form is also available in PDF format if you prefer to print it out and complete it manually.

Doctor being seen	Dr. Mary Arenberg Dr. George Schroeder
Name (required)
E-mail Address
Sex	Male Female
Birth Date	January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    Age
Social Security Number
Marital Status	Married Single Widow Divorced Separated
Street
City
Zip
Phone	( ) -
Employer
Who would you like us to contact in case of emergency:
THIS SECTION REFERS TO YOUR SPOUSE:
Spouse's Name
Birth Date	January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Social Security Number
Employer
Emergency Contact
Phone	( ) -
PERSON RESPONSIBLE FOR BILL, IF DIFFERENT THAN ABOVE:
Name
Phone	( ) -
Street
City
State	Alaska Alabama Arkansas American Samoa Arizona California Colorada Conneticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virgin Islands Vermont Virginia Washington Wisconsin West Virginia Wyoming Other...      Zip
INSURANCE INFORMATION:
PRIMARY INSURANCE
Place of Employment
Insurance Company
Street Address
City
State	Alaska Alabama Arkansas American Samoa Arizona California Colorada Conneticut District of Columbia Delaware Florida Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virgin Islands Vermont Virginia Washington Wisconsin West Virginia Wyoming Other...      Zip
Group #
I.D. #
Whose Insurance
Insured's Date of Birth January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Relationship to Patient
Family Members Covered by this Policy
SECONDARY INSURANCE
Place of Employment
Insurance Company
Street Address
City
State	Alaska Alabama Arkansas American Samoa Arizona California Colorada Conneticut District of Columbia Delaware Florida Federated States Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virgin Islands Vermont Virginia Washington Wisconsin West Virginia Wyoming Other...      Zip
Group #
I.D. #
Whose Insurance
Insured's Date of Birth January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Relationship to Patient
Family Members Covered by this Policy
I understand that the information on this page will be sent to Plymouth Family Physicians, S.C. and that this submission is not secure. If you are concerned, don't click the Submit button and PRINT THIS FORM or SAVE IT AS A FILE after completing it. You can then mail it or drop it off at the office. If you choose to complete this form at the office, please arrive at least 30 minutes before your appointment to complete all paperwork.

Additionally, the following signed statements will need to be on file at our offices:

I, the undersigned, have insurance coverage with the aforementioned insurance company, and assign directly to Plymouth Family Physicians all medical benefits for services rendered. I understand that I am financially responsible for all charges whether or not, paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all of my insurance submissions. This authorization is in effect until I choose to revoke it in writing.

Signature:________________________________________________________

MEDICARE PATIENTS

I request that payment of authorized Medicare benefits be made to Plymouth Family Physicians for any services furnished me by that provider. I authorize any holder of medical information about me to release it to the Health Care Financing administration and its agents any information about me to release needed to determine these benefits payable for related services. If other health insurance is indicated in item 9 of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or the agency shown. This authorization is in effect until I choose to revoke it in writing.

Signature:________________________________________________________