F Parker Thornton MD LLC

Today's date * Last Name * First Name * Date of Birth * Gender * Social Security Number * Age * Marital Status Address * Email * Home phone# Mobile phone# Work phone# Preferred method of contact * Spouse/Parent Name Patient Employer or School Referral Source Primary Care Physican Preferred Pharmacy/location Other family members previously treated Emergency Contact Name * Emergency Contact Phone# * Is this a work related injury? * Is the injury due to an accident? *

Insurance Information - please enter your primary and secondary (if applicable) insurance information.

Insurance Company Name * Insured name * Relationship to the Patient * Policy/ID# * Group# Insurance Company Name Policy/ID# Group#

Insurance Release of Information, Authorization and Assignment: I request that payment of authorized Medicare or other insurance company/carrier be made on my behalf to F. Parker Thornton M.D. L.L.C. for any services furnished to me by that party who accepts assignments/physician. Regulations pertaining to Medicare assignment of benefits apply. I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries any information needed for this or a related Medicare claim/other insurance company claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits to the party who accepts assignment. I understand it is mandatory to notify the healthcare provider of any other party who may be responsible for paying for my treatment.(Section 1128B of the Social Security Act and U.S.C. 3801-3812 provides penalties for withholding this information.)

I agree with the Insurance Release of Information, Authorization & Assignment Statement Above *

Please submit, thank you.