ࡱ>    !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxRoot EntryZ O2 PiyCONTENTS CompObjVSPELLING(_ Policy Holder ________________________________ Relationship to Patient ____________________ ASSIGNMENT OF BENEFITS I hereby assign payment of benefits of authorized MEDICARE BENEFITS and any other medical and/or surgical benefits, to include MAJOR MEDICAL BENEFITS to which I am entitled to be made either to me or on my behalf to ALAN F. JACKS, M. D., P.A., for any services furnished me by that physician/supplier. I authorize any holder of medical information about me to release any information needed to determine these benefits payable for related services. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR  ALL CHARGES WHETHER OR NOT PAID BY SAID INSURANCE, I HEREBY AUTHORIZE SAID ASSIGNEE TO RELEASE ALL INFORMATION NECESSARY TO SECURE PAYMENT. Date ______/_____/_________ Signature _________________________________________________________ Witness __________________________________________________________ Please return the completed form to the Check-In Area as soon as possible P. O. Box 476 ALAN F. JACKS, M. D. Phone: 828-874-0555 Rutherford College, NC 28671 al Security # _______-______-_______ Person to contact not living at the same address ______________________________________________ Relationship to patient ________________________ Phone ( ) _*(prfnl  x 2 4 X tvRv"$v  2n(2"'( ) @S  !"p""1CHNKWKS TEXTTEXTnFDPPFDPPFDPCFDPCSTSHSTSH STSHSTSH 2SYIDSYIDP SGP SGP d INK INK h BTEPPLC l BTECPLC FONTFONT RTOKNPLC STRSPLC !:PRNTWNPR",FRAMFRAM>TITLTITL,DOP DOP (gical benefits, to include MAJOR MEDPATIENT INFORMATION Note: Payment is expected at the time services are rendered. (Please Print Clearly) Date _______/______/_________ Patient s Full Name _________________________________________________________________ Address ___________________________________ Home Phone ( )_______-________ __________________________________________ Date of Birth _______/______/________ Sex Male Female Marital Status M W S D Patient s Social Security # ______-_____-________ Occupation ________________________ Patient s Employer __________________________ Work Phone ( ) _______-___________ Referring Physician __________________________ Family Physician ____________________ Responsible Party ___________________________ Relationship to Patient ________________ (if other than patient or a minor) Spouse/Parent of Minor Name _________________ Date of Birth _______/_______/_________ Employer __________________________________ Occupation __________________________ Work Phone ( ) ________-__________ Social Security # _______-______-_______ Person to contact not living at the same address ______________________________________________ Relationship to patient ________________________ Phone ( ) _________-_______________ PRIMARY INSURANCE Insurance Company ___________________________ Identification Number ____________________ Group Number ______________________________ Date of Birth _______/______/____________ Policy Holder ________________________________ Relationship to Patient ___________________ SECONDARY INSURANCE Insurance Company ___________________________ Identification Number ____________________ Group Number _______________________________ Date of Birth ________/_______/__________ (*DFn4 V vv   n~ll "|"  "  "!"  "!"  "|" $ "PS" $-  "PS"  "PS"  77 " " ttnn>7,Times New RomanSymbol  """ " " " " " "H) (08@SPCSPCSPCSPCSPCSPC  " " "XXK*KGHP Photosmart 2700 series!@h߀ odBeRLdExplorerdHBeںںHP Photosmart 2700 series0 series,LocalOnly,DrvConvert+winspoolHP Photosmart 2700 seriesPhotosmart2700seriesF"t;""оk"$c"` "``""A."@"t;""оk""` "``"."registration form.wps("""" (" ox 476 ALAN F. JACKS, M. D.  Z O2Quill96 Story Group Class9qyyy