New Patient Enrollment Form – Dr. Michael Lacey

Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone*

Area CodePhone Number
Cell Phone

Area CodePhone Number
E-mail
Preferred Method of Communication*

Home PhoneCell PhoneEmail
Date of Birth*

MonthDayYear
Sex*
Emergency Contact*

First NameLast Name
Phone Number*

Area CodePhone Number
Referring Physician

First NameLast Name
Phone Number

Area CodePhone Number
Taking any medications, currently?*

YesNo
If yes, please list it here
Are you allergic to any medications?*

YesNo
If yes, please list it here
Medical Insurance Information Primary
I will pay out of pocket
Company Name
Policy Holder Name
Member ID Number
Medical Insurance Information Secondary
Company Name
Policy Holder Name
Member ID Number
Please upload a copy of the front and back of your insurance card(s)*

Browse Files

Cancelof
I certify that I have read and agree to Drs. Lacey’s payment policy. I am eligible for the insurance indicated on this form and I understand that payment is my responsibility regardless of insurance coverage. I hereby assign to Dr. Lacey all money to which I am entitled for medical expenses related to the services performed from time to time by Dr. Lacey. I authorize Dr. Lacey to release any medical information to my insurance carrier or third-party payer to facilitate processing my insurance claims. I understand that failure to pay outstanding balancing within 90 days of notification of the amount due will result in submission to an outside collection agency. A $30.00 returned check fee will be charged for checks returned due to insufficient funds.

MEDICARE BENEFICIARIES: I request that payment of authorized Medicare benefits be made to Dr. Lacey. I authorize any holder of medical information about me to release to CMS and its agents any information needed to determine these benefits or the benefits payable for related services.
Signature

Clear
Should be Empty: