Catherine P. Montgomery, M.D.

Available Forms

PATIENT INFORMATION

Date *

Last Name *

First Name *

Middle Initial

DATE OF BIRTH *

Street Address *

City *

State *

Zip Code *

This is required for access to the patient portal.

Sex *

Marital Status *

Employed *

Student *

School Name

Employer Name

Employer Address & Phone

Preferred Phone *

Above Phone is *

Private

Shared

Messages can be left.

Do not leave messages.

Speak only to patient.

May speak to all who answer phone.

Preferred Method of Contact *

INSURANCE NAME *

INSURANCE ID NUMBER *

INSURANCE ADDRESS/PHONE *

Subscriber's Last Name *

Subscriber's First Name *

Subscriber's Middle Initial

Subscriber's Birth Date *

Subscriber's Relationship to Patient *

Person Responsible for Account *

Emergency Contact Name *

Emergency Contact Phone *

PREFERRED LOCAL PHARMACY

Name, Street, City

Assignment of Benefits *

I authorize payment of medical benefits to myself of the names provided, for professional services rendered. I also authorize the release of any medical information necessary to process the claim.

I understand that I am financially responsible for all charges and for all services rendered to me by this office. This includes the balance remaining after payment of possible insurance benefits. I also understand that it is my responsibility to know my benefit coverage.

Signature

This form can be printed and signed ahead. Otherwise, this form can be printed and signed at the office.

Date signed

* Required field