INSURANCE INFORMATION

Primary

Insurance Name__________________

Name of Insured______________________

Insured DOB___/___/_____ Insured's ID#_______________

Group#_______________

Employer Name___________________ Employer

address________________________

Employer Phone____-____-____ Relationship of patient to

insured__________________

Secondary

Insurance Name____________ Name of

Insured_______________________

Insured DOB___/___/____ Insured's ID# _______________

Group# ________________

Employer Name___________________ Employer address

________________________

Employer Phone ____-____-____ Relationship of patient to insured _______________

Pharmacy

Name ______________________________________

Phone ____-____-____

Emergency Contact________________ Relationship

__________Phone ___-____-____

Referred By _____________ Primary Physician

_____________Phone ____-____-____

 
PATIENT AND RESPONSIBLE PARTY AUTHORIZATION
I authorize Middlesex Community Medical Care LLC. to apply for benefits on my behalf for the covered services rendered and request that payments from the above named insurance company (ies) be made directly to: Middlesex Community Medical Care LLC. for the treated person named. I certify that the information reported with regard to my insurance coverage is correct and further authorize the release of any necessary information, including medical information for this or any related claim to the above named agent. I permit a copy of this authorization to be used in place of the original.

IN ALL CASES, PROFESSIONAL FEES ARE THE PATIENT, SPOUSE, GUARDIAN AND/OR PARENTS' RESPONSIBILITY. Finance Charge (no charge if paid in 30 days of billing date) is computed by a "Periodic Rate" of 1 ½ % per month, which is an ANNUAL PERCENTAGE RATE of 18% applied to the previous balance without deducting current payments and/or credits appearing on any given bill. Patient or responsible party (ies) further agree to pay any and all collection fees incurred and legal expenses, including but not limited to a all collection Agency and Attorney fees ( at 33% ), all court related costs, service and filing fees, interrogatory and garnishment fees as well as any interest that may be adjudicated for the collection of past due debts.
Print Name :
Signature :
Date :
   
   
 
 
 
 
 
 
+ Welcome to Middlesex Community Medicalcare, a place you can rely on for your primary healthcare needs.
+ At MCM, physician and staff is not only committed to providing you with the quality care but also with giving the compassion and comfort you deserve.
+ Our main focus is on prevention and treatment of most common conditions affecting adult population age 18 and above.
+ Along with office based practice, hospital admissions, nursing homecare and good refferal services are also provided.
 
Patient Registration Form
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