Tennessee Women's Care, P.C. | Obstetrics and Gynecology

Date:
Provider:
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Patient:
Date of Birth:
	Age: Sex: Female Male
Marital Status:
Address:
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Home Phone (include area code):
Work Phone (include area code):
E-mail:

Employer:
Employer's Address:
Primary Insurance Company:
Policyholder's Name:
Date of Birth
Relationship to Patient:
Mailing Address:
City:
State:
Zip:
ID#
Group #
Policy #

Secondary Insurance Company:
Policyholder's Name:
Date of Birth
Relationship to Patient:
Mailing Address:
City:
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Zip:
ID#
Group #
Policy #


Last Name:
First Name:
Middle Initial:
	I hereby agree to allow Tennessee Women's Care to leave messages on my answering machine, including medical information.
	I do not agree to allow Tennessee Women's Care to leave messages on my answering machine, including medical information.

In case of emergency contact:
Address
Home Phone
Work Phone

ADVANCE BENEFICIARY NOTICE/AGREEMENT: Insurance rarely covers treatment given by phone; some such examples include unscheduled prescription refills between office visits. Such charges will not be filed with your Insurance Company. Your Insurance also may not cover properly filed charges for certain test, visits, or imaging procedures, if it deems them "uncovered". Your signature indicates that you agree to be financially responsible for these types of services when they are provided.
Name:
Today's Date:
INSURANCE AND COLLECTION AGREEMENT: I hereby authorize Tennessee Women's Care to furnish diagnosis codes to my insurance carrier(s) concerning my illness, medical conditions, and treatment(s) for billing purposes. I hereby assign Tennessee Women's Care all insurance payments for medical services rendered to myself and/or my dependents. I agree that I am responsible for my bill regardless of Insurance coverage. In the event that Tennessee Women's Care deems it necessary to pursue collection of my and/or my dependents account(s) through an attorney or collection agency, I agree to pay all costs of collection, including reasonable attorney's fees and court costs.
Name:
Today's Date: