JAMES K. ROTCHFORD, MD, MPH

PATIENT QUESTIONNAIRE

Today's date: ___________________

Last Name: ____________________________First: _________________ Middle:________

Name and signature of Responsible Party if patient is a Minor:________________________

Address: ______________________________________ Soc.Sec.No. ___/___/___

City: ______________________ State: _________ Zip: ___________

Home Phone: _________________ Office/Message Phone: _____________

Sex: Male __ Female __ Date of Birth: ___/___/___

Marital Status (circle one): Married - Single - Divorced - Widowed - Separated- Other

What is your insurance? _______________Medicare #_____________________

Please read: Payment is expected at the time of the visit. Credit Cards accepted. EZ-Pay plans available.

If it becomes necessary to turn this account over to a collection agency the information on this page may be given to them. By signing this form you authorize James K. Rotchford, MD, to release any information required by your insurance company or benefits carrier for claims from James K. Rotchford, MD, acknowledge receipt of a copy of this form, authorize treatment of the patient above, and agree to pay all fees and charges for such treatment.

I request that payment of authorized medicare benefits be made either to me or on my behalf for any services furnished me by James K. Rotchford, MD, including physician services. I authorize any holder of medical or other information about me to release to the Health Care financing administration and its agents any information needed to determine these benefits or benefits for related services.

Signed: __________________________________________________________

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If the patient named above is not responsible for the bill, please complete the following:

Address: _____________________________ City: _______ State: ____ Zip: _______

Relation to Patient: (Please Circle One) Spouse - Parent - Child - Other

Responsible Party's Date of Birth: ___/___/___ Soc. Sec. No. ___/___/___