ALLERGY-ASTHMA-RHEUMATOLOGY ASSOCIATES, P.C.
1200 East Genesee Street, Suite 103, Syracuse, NY 13210
Phone: 315-478-2339 FAX:
315-478-0439
MICHAEL G. SHEEHAN, M.D.
N. ANDREI POPESCU, M.D.
HARCHARAN SINGH, M.D.
Allergy/Immunology Allergy/Immunology Allergy/Immunology
Certified by the American
Board of Allergy and Immunology
PATIENT
INFORMATION SHEET
Name (first)_________________(M)___(last)_______________________________________________
Date of birth:_____________Age:____________Sex: M/F___
Marital status S/M/W/D______________
Address
(street)_______________________________________________________________________
City, State, Zip________________________________________________________________________
Phone #____________________________________Social
Security #____________________________
Work
#______________________Employer________________________________________________
Employer’s address:___________________________________________________________________
Referring physician:_______________________If student,
school name ___________________ Full PT
Physician address
:____________________________________________________________________
RESPONSIBLE
PARTY OR SPOUSE INFORMATION
Name________________________________________Relationship
to patient_____________________
Address (street)
______________________________________________________________________
City, State,
Zip________________________________________________Phone #_________________
Social Security #__________________________Driver License
#______________________________
Work
#______________________Employer________________________________________________
Employer’s
address____________________________________________________________________
Friend or relative not living with you
______________________Phone # __________________________
INSURANCE INFORMATION
Medicare #_________________________________________________________________________
Ins. Co. # __________________________________________________Phone #__________________
Ins. Co. address______________________________________________________________________
Group #______________________________________ Certificate
or ID#________________________
Insured’s name____________________________ Relationship
to patient: Self–Spouse- Dependent
Insured’s
employer____________________________________________Phone__________________
Employer’s
Address:_________________________________________________________________
Insured’s SS # _____________________________Date of
birth:_____________________ Sex: M
F
I hereby assign, transfer and set over to
Allergy-Asthma-Rheumatology Associates all of my rights,
title and interest to my medical reimbursement benefits
under my insurance policy. I authorize
the release of any medical information needed to
determine these benefits. The authorization shall
remain valid until written notice is given by me revoking
said authorization. I understand that I
am financially responsible for all charges whether or not
they are covered by insurance.
PARENT/PATIENT SIGNATURE ____________________________
DATE: ____________________