Patient First Name:

Middle Int:

Last Name:

Mailing Address:

City:

State:

Zip Code:

Primary Phone #:

Secondary Phone #:

Date of Birth:

Age:

Sex:

Social Security #:

Disabled

Retired

Retired Employer:

Occupation

In case of emergency notify:

Phone:

Insurance Information

Primary Insurance:

Address of Company:

Subscriber/Insured

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ID #:

Group #:

Subscriber Social Security #:

Subscriber Date of Birth:

Second insurance Information

Secondary Insurance:

Address of Company:

Subscriber/Insured

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ID #:

Group#:

Subscriber Social Security #:

Subscriber Date of Birth:

Is your visit today due to an Accident?

Work

Auto

Date of Injury

Authorization and Assignment

I request that payment of authorized Medicare, Medicaid, Commercial Carrier, Workman's Compensation, or VA benefits on my behalf be made to Northwest Arkansas EMG Clinic for any services provided to me. I authorize Miles Johnson, M.D. to release to the Health Care Administration and its agents any information needed to determine benefits payable for related services. I understand that I am responsible for any deductible, co-payments or services not covered by my insurance carrier. I authorize the physician to release any information required by my insurance company and/or another physician. I acknowledge the offer of Notice of Privacy Practices. I give permission to release my medical records to myself at my request.
I authorize treatment provided by Miles Johnson, M.D.

Authorization to discuss my medical information with:

Date:

E-Signature

Please sign electronically below.

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Patient Information

Insurance Information

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Second insurance Information

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Authorization and Assignment

E-Signature

E-Signature Consent Patient Signature or Legal Guardian (if minor)

E-Signature Consent
Patient Signature or Legal Guardian (if minor)