Malibu Specialty Center
28990 Pacific Coast Highway Suite 222
Malibu, California, 90265
3104574898

 

 
Patient's Personal Information

Patient Name:
Age:
Gender:
Birthdate:    
Marital Status:
Street Address:
City:
State:
Zip code:
Telephone:
Home #:
Work #:
Employer Name/Address/Phone:
Allergies to drugs:
Reason for Visit:
Current Medications:
Referring Physician Name/Address:
Friend Relative not living with you
Phone number:
   

 
Primary Insurance Information

Insurance Name:
Insured Name:
Birthdate:    
ID Number:
Group/Policy Number:
SS # of Insured:

 
Secondary Insurance Information

Insurance Name:
Insured Name:
Birthdate:    
ID Number:
Group/Policy Number:
Employer Name/Address/Phone :
(If different from above)

 
Responsible Party Information (If different from Patient)

Full Name:
First
MI
Last
SS Number:
Home Address:
Street:
City:
Zip code:
Mailing Address
(if different)
Street:
City:
Zip code:
Gender:
Birthdate:    
Marital Status:
Telephone:
Home #:
Work #:
Employer Name/Address/Phone :
(If different from above)

 
Spouse Information (If different from Patient)

Spouse Name:
Birthdate:    
Employer's Name/Address/Phone :
DO YOU HAVE A LIVING WILL OR DURABLE POWER OF ATTORNEY? YES  NO
WOULD YOU LIKE INFORMATION ON A LIVING WILL OR DURABLE POWER OF ATTORNEY? YES  NO
INFORMATION PACKET GIVEN TO PATIENT: DATE:_____________________  INITIALS:______________
Read the following release of information. Please sign and date.
I agree to and authorize medical treatment as deemed necessary by Medical Specialty Clinic, P.C. I hereby authorize Medical Specialty Clinic, P.C. to furnish information concerning my treatment to insurance companies as deemed necessary, I hereby irrevocably assign to Medical Specialty Clinic, P.C. all insurance benefits payable to me by my insurance company, not to exceed the charges shown. I understand that I am financially responsible for any amounts that are not covered by my insurance company and this authorization. Medical Specialty Clinic, P.A. cannot accept responsibility for collecting insurance claims or for negotiating a settlement on a disputed claim. I understand that I am responsible for my account. The undersigned further agrees that in the event his/her account is turned over to an attorney, the undersigned shall be responsible for all costs of collection, including out of pocket expenses, court costs, and attorney fees.

I request that payment of authorized Medicare benefits be made either to me or on my behalf to Medical Specialty Clinic, P.C. for any services furnished me by that clinic. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable for related services.