NIRSCHL ORTHOPAEDIC CENTER

                         FOR SPORTS MEDICINE AND JOINT RECONSTRUCTION                                                                             

     1715 N George Mason Drive, Suite 504, Arlington, Va. 22205        Fax: (703) 522-2603

        

  Robert P. Nirschl, M.D., M.S.                                           William C.Lennen, M.D.

    (703 525-2200                                                                          (703) 525-5518

 

  Eric J. Guidi, M.D.                                                              Patrick St. Pierre, M.D.

    (703) 841-0551                                                                        (703) 894-1123

 

   Derek Ochiai, M.D.

    (703) 525-8183    

 Patient Name: Date of Birth:  Age: Gender: M F
Marital Status:
S M D W
Street Address Apt # City, State Zip Code
Mailing Address (if different)  Home Phone Work Phone
Social Security #
Employer Name and Address Occupation Cell or Pager:
Emergency Contact? To whom may we speak regarding your medical file?
Who is your Family Physician?

Telephone: 		What Medications are you taking?
Most Recent Date of Onset X-rays taken for this problem? ______
Where?__________________________
When?__________________
Do you have them with you?_________		 Do you have any allergies to medicine?
Part of the body to be examined

__________________________
Name: Relationship to patient:___________________________________
 If Workers Compensation Claim, Who is your adjuster?  Telephone #?
 		 Street Address, Apt # City, State, Zip Code
Responsible Partys Employer

 		 Group# Subscribers Employer
Home Phone, Work Phone, Cell, or Pager: Insurance Company Name
ID #		  
Mailing Address
 
Subscribers Name  Subscribers Date of Birth Subscribers Social Security #
Telephone:  
Effective Date of Insurance: Group# Subscribers Employer Subscribers Name Subscribers Date of Birth
Insurance Company Name
Subscribers Social Security #
 		 Mailing Address Effective Date of Insurance: Telephone:

                                                          
I, ______________________________________________, hereby authorize the above-named physician to apply for benefits on my behalf for covered services rendered. I request payment from the above-named insurance companies be made directly to the above-named physician. My signature certifies the information I have provided is correct and further authorizes the release of any necessary information, including medical information for this claim to be paid. This authorization is in effect for all future claims until I give written notice to revoke it. I permit a copy of this authorization be used in place of the original assignment.
I further acknowledge that I am financially responsible for any balances not covered by my insurance plan. Any accounts not paid in a timely fashion will be referred to an outside collection company. If this action is taken, I understand I will be held responsible for any collection agency costs to this office including legal fees.

Signature:____________________________________________________________________________________