Ford Medical Associates, PA.
Patient Billing Information Data Sheet
Please Print Clearly - This Information is Essential to Accurate Information in our Computer

Patient's Name_______________________________________________________
Address______________________________________
City, State, Zip_______________________________________________________

Home Phone (_______) _______-____________
Work Phone (_______) _______-____________
Is work phone Patient's? _____ or Parent's?_____

Age______Birthdate: ________________ Sex: M______ F______ Social Security #_______________________
Responsible Party/Guarantor Name______________________________ Home Phone (______) ______-______________
Relationship to Patient: Parent_______ Spouse________ Other__________ Work Phone (_______) _______-____________
Address_____________________________________________________ City, State, Zip______________________________
Employer Name and address_____________________________________________
If patient is under 18 give names of: Mother_____________________________ Father_________________________ or Guardian__________________________
Patient's Marital Status: Single___ Divorced ____ Married___ Name of Spouse_______________________________________
Employment Information Is: Patient's _____ Parent's _____ Spouse's_____    Do you have Insurance? Yes_____ No______
If you are not paying for today's visit and want us to submit a claim to your Insurance, the following Information must be completed. Please give our receptionist your insurance card so we can obtain a photocopy for our records. Thank you.
PRIMARY HEALTH INSURANCE POLICY HOLDER INFORMATION
Insurance Company_________________________________________ Insured's Name_________________________________________
Address__________________________________________________ Relationship to patient: Spouse______ Parent______ Other______
City, State, Zip ____________________________________________ Insured's Employer ______________________________________
Phone (_______) _______-____________ Address________________________________________________
Insurance ID#________________________ Group#______________ City, State, Zip__________________Phone_____________
SECONDARY HEALTH INSURANCE POLICY HOLDER INFORMATION
Insurance Company_________________________________________ Insured's Name______________________________
Address__________________________________________________ Relationship to patient:: Spouse______ Parent______ Other______
City, State, Zip ____________________________________________ Insured's Employer ______________________________________
Phone (_______) _______-____________ Address________________________________________________
Insurance ID#________________________ Group#______________ City, State, Zip__________________Phone_____________
OTHER INSURANCE POLICY HOLDER INFORMATION
Insurance Company_________________________________________ Insured's Name______________________________
Address__________________________________________________ Relationship to patient: Spouse______ Parent______ Other______
City, State, Zip ____________________________________________ Insured's Employer ______________________________________
Phone (_______) _______-____________ Address________________________________________________
Insurance ID#________________________ Group#______________ City, State, Zip__________________Phone_____________
Describe problem, injury or reason for seeing the Doctor____________________________________________________________________
Date when problem or injury occurred ___________________     Referred to our office by___________________________________
Please read & sign authorization which follows: I hereby authorize release of any information necessary for completion of insurance claims and direct payment to AYERS & FORD, MD. PA.. I undestand I am financially responsible for all charges not covered by Medical Insurance, including non-covered services, collection agency fees, court costs and/or attorney fees necessitated by any collection activity caused by my failure to clear any balance due. I permit a copy of this authorization to be used in place of an original.
Signature of Patient (or Parent)____________________________________________________ Date______________________