Cape Medical Billing Patient Form

 

Section 1: Patient Information
Patient Account Number:   
Patient Name:  Last First Middle Initial Suffix:
Patient's Social Security Number: - -   *Patient's Date of Birth: / /  (mm/dd/yyyy)
 
Section 2: Patient Demographic Information
Please use this section for changes and corrections to your demographic information to ensure that your insurance claims are processed in timely fashion.
Patient Address:  (House number and street)
Apartment Number:  (if applicable)  City:  State:  Postal Code:
Phone Number 1:( ) -    Phone Number 2:( ) -  
 
Section 3: Guarantor Information
Please fill in this information if you are the parent, guardian or legal responsible person for the patient.
Guarantor Last Name: First Name: Middle Initial:
Phone Number 1:( ) -    Phone Number 2:( ) -  
Guarantor Address: (House Number and Street)
Apartment Number  (if applicable) City:  State: Postal Code:
 
Section 4: Primary Insurance Information
Please fill in all information
Insurance Company Name:
Address: (Address to submit claims to)
City:  State: Postal Code:
Phone Number:( ) - Fax Number:( ) -
Policy Number: Group Number: (if applicable)
Subscriber's Last Name: First Name: Middle Initial:
Subscriber's Date of Birth: / / (mm/dd/yyyy)
Relationship to Patient: Explain, if Other:
Effective Dates of Insurance: / / To / /  (mm/dd/yyyy)
 
Section 5: Motor Vehicle Accident / Worker's Compensation Claim
Please use this section to supply information if this is due to an auto accident or worker's compensation claim.
Type of Claim: Is your Claim
Insurance Company Name:
Address:   City:  State: Postal Code:
Claim Number: (This is the number given by your adjuster, not the policy number)
Date of Accident: / / (mm/dd/yyyy)  Adjuster's Name:
Adjuster's Phone Number:( ) - Adjuster's Fax Number:( ) -
 
Section 6: Secondary Insurance Information
Please fill in all information
Insurance Company Name:
Address: (Address to submit claims to)
City:  State: Postal Code:
Phone Number:( ) - Fax Number:( ) -
Policy Number: Group Number: (if applicable)
Subscriber's Last Name: First Name: Middle Initial:
Subscriber's Date of Birth: / / (mm/dd/yyyy)
Relationship to Patient: Explain, if Other:
Effective Dates of Insurance: / / To / /  (mm/dd/yyyy)
 
Section 7: Tertiary Insurance Information
Please fill in all information
Insurance Company Name:
Address: (Address to submit claims to)
City:  State: Postal Code:
Phone Number:( ) - Fax Number:( ) -
Policy Number: Group Number: (if applicable)
Subscriber's Last Name: First Name: Middle Initial:
Subscriber's Date of Birth: / / (mm/dd/yyyy)
Relationship to Patient: Explain, if Other:
Effective Dates of Insurance: / / To / /  (mm/dd/yyyy)
 

Section 8: Additional Comments
Please use this area to add any information that you feel would be important for us to make sure that your claim is handled in a expeditious manner.