Updated: _______________ PATIENT INFORMATION

Gulf Coast Facial Plastics & ENT Center

Both front and back must be filled out completely in order to be treated.

Patient Name Minor Child – yes or no (circle one) Date

Guardian/Parent SSN# (Parent)_______________

Permanent Address City State Zip Temporary Address City State Zip

Home Phone Sex M / F Date of Birth / /

SS# / / Marital status: S M W D Email

Spouse’s/Significant Other’s Name

Emergency Contact Emergency Contact Phone

Circle how you heard about us?: Yellow pages/Newspaper/Friend/Radio/Magazine/Other

If you were referred by an MD, who?

Place of Employment Phone Ext.

May we call you at work to schedule surgery? Yes No

May we send you mail other than billing? Yes No

INSURANCE INFORMATION (please provide insurance card and picture ID)

Primary Insurance Co.___________________________________ Policy number____________________________

Group Number__________________________________ Relationship to Insured____________________________

Insured’s Name__________________________________________________________________________________

Insured’s (primary policy holder, not necessarily patients) Date of Birth___________/__________/____________

Insured’s SS#_______________/___________________/______________________

Secondary Insurance Co._____________________________ Policy Number_________________________________

Group Number___________________________________________________________________________________

Insured’s Name___________________________________________________________________________________

Insured’s (primary policy holder, not necessarily patients) Date of Birth___________/__________/_______________

Is this visit accident as the result of an accident? Y N If yes, date of occurrence_____/______/_______

PATIENT RELEASE & ASSIGNMENT FORM

I HEREBY AUTHORIZE Gulf Coast Facial Plastics & ENT Center to be my personal representative, which allows the practice to: (1) submit any and all appeals when my insurance company denies me benefits to which I am entitled, (2) submit any and all requests for benefit information from my insurance company, (3) initiate formal complaints to any State or Federal agency that has jurisdiction over my benefits, and (4) release to your company or its representative any information including diagnosis and the records of any treatment or examination rendered to me during the period of such medical or surgical care. I fully understand and agree that I am responsible for full payment of the medical debt if my insurance company refuses to pay 100% of my benefits. Payment will be rendered within ninety (90) days of any and all appeals, or request, for information. I also agree that any fines levied against my insurance company will be paid to Gulf Coast Facial Plastics & ENT Center for acting as my personal representative.

PATIENT (or responsible party’s) SIGNATURE: __________________________________________________________

MEDICARE PATIENTS: PLEASE SIGN BELOW FOR MEDICARE RELEASE AND ABOVE, IF YOU HAVE A SUPPLEMENT.

THIS IS THE MEDICARE LONG-TERM RELEASE & ASSIGNMENT

I hereby authorize payment to Gulf Coast Facial Plastics & ENT Center of benefits due to me from my insurance company otherwise payable to me if assignment is accepted. I further authorize the release of any medical information required by my insurance carrier. A copy of this authorization may be used in lieu of the original. I authorize any holder of medical or other information about me to release the information to the Social Security Administration & Health Care Financing Administration or its intermediaries or carriers any information needed for this, or a related; Medicare claim. I request payment of medical insurance benefits either to myself or to the party who accepts assignment.

PATIENT SIGNATURE: _____________________________________________________________________________

Consent For Treatment

I, the undersigned, on behalf of the patient whose name appears on the front of the form, consent to, and authorize all, diagnostic and therapeutic, treatments deemed necessary by the attending physician, or his staff, in accordance with today’s medical standards and consent for future treatment may be revoked in writing and will not be revoked by implication. Further,

Malpractice

I, the patient, and/or my representative, agree not to bring a frivolous medical malpractice case, or cause of action, against Gulf Coast Facial Plastics & ENT Center, Dr. Daniel Daube, and/or Dr. James Beggs. Furthermore, should a meritorious medical malpractice case, or cause of action, be initiated or pursued, I, the patient, and/or my representative agree to use an expert medical witness(es) who adhere(s) to the guidelines and/or code of conduct, defined by the specialty society(ies) for expert witnesses in the area(s) of medicine who would typically have the background and experience to opine on such a case. Further,

Notice of Privacy

I have read the Notice of Privacy for Gulf Coast Facial Plastics & ENT Center that is posted at the front desk, I have received a copy and I agree with this language. I understand that I may obtain a copy from www.danieldaube.com or from the office. Further,

Consent To Photograph/Video Tape

I authorize and give permission to Gulf Coast Facial Plastics and ENT Center to record me, or any parts of my body deemed advisable, for diagnostic, educational, research, in the event of legal action, or for advertising purposes. I further authorize the use of such recordings for teaching purposes, or to illustrate scientific papers, or lectures, at any time hereafter without inspection or approval on my part of the finished product, or the specific use to which this material may be applied. Consent can only be revoked in writing and will not be revoked by implication. I understand that modifications made on the computer cannot be guaranteed. They are intended only to help illustrate possible results obtained by surgery. However, if you want limitations to apply, please note:_____________________________________________________________________

Custody

I have primary residential custody of the minor being treated and/or understand that if I do not, written permission is required for care. Further,

Collections

All accounts which are turned over to collections, will be assessed all fees from the collection agency, as well as any attorney fees and/or court costs. Please understand that turning accounts over for collection will be done only when NO payments are made and a collection letter from our office has previously been sent. We also make every effort to locate patients by return mail before we send an account over to collections, so please notify our office if you have a change of address.

PATIENT SIGNATURE______________________________________________________

PARENT/GUARDIAN SIGNATURE____________________________________________

PLEASE CIRCLE THE METHOD OF PAYMENT FOR TODAYS VISIT:

CASH / CHECK / CHARGE CARD / DEBIT CARD

07/19/2006