Name of insured:       Date of Birth:  

Home Phone:          Work Phone:

Cel Phone:           Emergency Contact Phone:

Address:

City:  State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NJ NH NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AA AE AP AS FM GU MH MP PR VI ZIP:

INSURANCE COMPANY NAME:

GROUP NUMBER:

Spouse Name: Child Name (1):

Child Name (2): Child Name (3):

CONSENT FOR MEDICAL CARE AND ASSIGNMENT OF BENEFITS

I hereby provide consent for all medical care and assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, private insurance, and any other health plan to Allen Family Clinic and Frisco Family Clinic.   This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information to secure the payment.

I AGREE                          I DO NOT AGREE

This statement is to inform you that you have no other insurance other than the policy given above. If you have additional insurance please complete section below.

Insurance Name:  

Policy Number:

Group Number: