This document contains patient information and insurance details. It collects the patient's name, address, phone numbers, email, date of birth, social security number, emergency contact, physicians, and how they heard about the center. It also records the primary and secondary insurance information including company name, claims address, ID and group numbers, policy holder name and details. Finally, it contains an authorization for the center to bill the insurance and for the patient to be responsible for any fees not covered by insurance.

1. PATIENT INFORMATION
First Name: __________________________________ Last Name: __________________________________________
Street Address: ______________________________________________________________________________________
City: _____________________________________ State: _____________________________ Zip:____________________
Phone #s Home: _______________________ Work: ______________________ Cell: ________________________
Email: ________________________________________________________________________________________________
Date of Birth: ______________________ SSN: __________________________ Marital Status: □S □M □D □W
Emergency Contact: _________________________________________________________________________________
Relationship: ________________________________________ Phone#: ______________________________________
Primary Care Physician (First & Last Name): _____________________________________________________
Referring Physician (First & Last Name): _________________________________________________________
Pharmacy: _____________________________ Pharmacy phone#: _______________________________________
How did you first learn about the Center for Innovative GYN Surgery?
(Please check all that apply.)
□ Doctor referral □ Hospital referral □ Insurance referral □ Friend / Relative
□ Internet (Which website? _________________ ) □ Print (Which publication? ________________ )
□ Television (Which channel? _______________ ) □ Radio (Which channel? ___________________ )
□ Other ___________________________________________________________________________________________

2. INSURANCE INFORMATION
Patient: First Name _______________________________ Last Name _____________________________________
Primary Insurance Company Name: ____________________________________ Co-pay $ ____________
Claims Address: _____________________________________________________________________________________
ID#: ____________________________________________ Group#: ____________________________________________
Policy Holder Name: ______________________________________ Relationship: _________________________
Policy Holder’s DOB: _____________________ Policy Holder’s SSN:__________________________________
Policy Holder’s Employer: _________________________________________________________________________
Secondary Insurance Company Name: __________________________________ Co-pay $ ____________
Claims Address: ______________________________________________________________________________________
ID#: ____________________________________________ Group#: ____________________________________________
Policy Holder Name: ______________________________________ Relationship: _________________________
Policy Holder’s DOB: _____________________ Policy Holder’s SSN:__________________________________
Policy Holder’s Employer: _________________________________________________________________________
PATIENT’S AUTHORIZATION:
I authorize the Center for Innovative GYN Surgery to apply for benefits on my behalf for services rendered by CIGS from
my insurance company, and that payment is made directly to CIGS. I certify that the information I have reported with
regards to my insurance coverage to be true and correct and further authorize the release of any necessary information
(to include medical information) for any related claims. I further understand that if my insurance plan requires me to
obtain a referral and if I do not have the necessary referral with me at the time of service, or if my referring physician will
not issue a referral, I am responsible for paying all fees for services owed to CIGS. I understand that if I do not have out-of
network benefits under my insurance plan and if the doctors of CIGS are not a participating provider under my insurance
plan, I am responsible for all fees for services rendered. I permit a copy of this authorization to be used in place of the
original. This authorization may be revoked by me in writing. I understand that nothing herein relieves me of the primary
responsibility and obligation to pay for medical services provided, when a statement is rendered. Any payments from my
insurance carrier made to me for services provided by any member of CIGS will be surrendered to CIGS. This includes
office visits, surgery or other procedures.
_________________________________ ______________________________
Patient / Guardian Signature Date