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Online Form

This form will be given to you when you arrive at our office. To save you waiting time you can now submit this information Online. Please fill out the form below and click "submit" to send us your information. We will print this out and have you sign it when you arrive. Please fill out as many of the fields as you can. If you choose to print this form, please fill it out first, print it and then sign it in the presence of the staff at Doctor Kaminsky's office.

Today's Date:
/ /
Date of Injury: / /
 
Patient Information
Patient's Name:


Last


First
Middle
Date of Birth: / /    
Gender: (M/F) Marital Status: (Single/Married)
Home Address: Apartment / Unit:
City: Zip:  
Social Security Number:
(i.e. 555-66-7777) 		D/L # : State:
Primary Phone:
(i.e. 123-456-7890) 		Other Phone:
(i.e. 123-456-7890)
Email: (i.e. name@domain.com)
 
Medical and Employment Information
Referred By:
Physician: Physician Tel.:
(i.e. 123-456-7890)
Employer:
Employer Address: Suite / Unit:
City: Zip:
 
Spouse / Emergency Contact Information
Spouse Name: Spouse's Telephone:
(i.e. 123-456-7890)
Emergency Contact: Emg. Contact Tel.:
(i.e. 123-456-7890)
 

Please complete the Insurance Information below

Insured Party: Self Spouse Parent Other - If other please describe below:

Name (If other than self):
Last First: Middle:

SS# (i.e. 555-66-7777)

Date of Birth: / / (i.e. 02/04/1980)

Insurance Company Name:

Phone: (i.e. 123-45-6789)

 

Authorization to Pay Medical Fees & Financial Agreement:

I hereby authorize my medical provider in charge of my case to furnish my insurance company with information concerning my treatment. A photcopy of this authorization will be considered as valid as the original. I hereby authorize and instruct my insurance company to pay by check, via mail, directly to:

Ilya Kaminsky, D.C., R.P.T, Inc.

6333 Wilshire Blvd, #101, Los Angeles, CA 90048

The medical expense benefits allowable and otherwise payable to me under my current insurance policy, including major medical benefits, as payable toward the total charge for professional service rendered. This payment will not exceed my indebtedness to above mentioned assignee and I agree to pay in a current manner any balance of said professional service charges over and above this insurance payment. If legal action becomes necessary to enforce payment, I agree to pay a reasonable attorney fee, and/or collection fee. In the event the insurance company proceeds are not applicable or are insufficient, I agree to pay the indebtedness individually.

Please type your name here and this form will be printed out at the office to be signed in person by you. If you wish to print the document yourself, please wait to sign it in the presence of the office staff. Thank you.

LAST NAME: FIRST NAME:

(PLEASE SIGN HERE IN THE PRESENCE OF THE STAFF/DOCTOR)

 

Signature: X______________________________________________________

 

 


 
 

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