PATIENT INFORMATION	PRIMARY INSURED INFORMATION
Name (last)   First   Middle   Street Address   City   State   Zip   Patient's Birth Date   Home Ph. No.   Social Security No.   Work Ph. No.   Employer or School Name   Occupation   Driver's License No.   Patient Status    Single       Married       Other       Employed    Full-Time Student            Part-Time Student Name of Spouse	Name (last)   First   Middle   Address (if Different)   Relationship   City   State   Zip   Insured's Birth Date   Sex    M    F Home Ph. No.   Social Security No.   Work Ph. No.   Insurance Name   Insurance Address   I.D. No.   Group No.   Employer

Do you have a Secondary Insurance Plan?   Yes    No   _______________________________

Patient referred by: _____________________________________________________________

INSURANCE SIGNATURE AUTHORIZATION

I authorize any holder of medical or other information about me to release to the insurance company any information needed for this or a related claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits to Faith Carlin, M.D. X _______________________________________

PAYMENT TERMS:

We will bill your insurance as a courtesy, however you are responsible for the bill whether or not your insurance pays.
We prefer payment on date of service. You may pay with cash or check.
A $7.00 rebilling fee (per month) may be added to all accounts with a pastdue balance over 60 days.