FORM - 3
Tapan K. Chaudhuri, M.D.
6225 Raytown Trafficway
Raytown, MO 64133
Today's Date ____________________ PCP _____________________
PATIENT INFORMATION :
Patient's Legal Name : ______________________________________________ Nickname ______________________
  (First M.I. Last)  
Address : ________________________________________________________________________________________
________________________________________________________________________________________________
  City State Zipcode
Phone Numbers :  Home ___________________ Work _________________ Emergency ________________________
Date of Birth : ___/___/_______ Social Security No.: ____________ Sex: M   F    Marital Status    S   M   D  W   Seperated
How did you learn about our office : ___________________________________________________________________
EMERGENCY INFORMATION :
Name of Person to notify :
_______________________________
Relationship :
_______________________________
Address :
_______________________________
_______________________________
Phone No : _____________________
(Does this match the above emergency number?)
EMPLOYMENT INFORMATION :
Employer :
________________________________
Employer's Address :
________________________________
Telephone : ______________________
Occupation : _____________________
Job Title : ________________________
Employed : Full-time Part-time
Family Members Living at Home/Age:
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
RESPONSIBLE BILLING PARTY :
Relationship to patient : Same
Spouse parent others
Name :
_______________________________
Address :
_______________________________
_______________________________
Social Security # : _________________
Birth Date : ______________________
Home Phone # : (____)_____________
Occupation : _____________________
Employer : ______________________
Employer' Address :
_______________________________
_______________________________
Employer's Phone # : ______________
PRIMARY INSURANCE INFORMATION :
  Medicine Medicare
  Insurance Self- Pay
Insurance Company :
________________________________
Certificate/ID # :
________________________________
Group/Policy # :
________________________________
Claim Mailing Address :
________________________________
________________________________
________________________________
________________________________
________________________________
PerCert Phone # : _________________
 
SECONDARY  INSURANCE  INFORMATION :
 
Insurance Company :
_______________________________
 
Certificate/ID # :
_______________________________
 
Group/Policy :
_______________________________
 
Claim Mailing Address :
_______________________________
_______________________________
_______________________________
ASSIGNMENT OF INSURANCE BENEFITS/RELEASE OF MEDICAL INFORMATION :
1: Authorization to Pay Benefits to Physician: I hereby authorize payment to Tapan K. Chaudhuri, M.D. for the surgical and/or medical benefits, if any, for his services.
 
2: Authorization to Release Information : I hereby authorize Tapan K. Chaudhuri, M.D. to release any information acquired in the course of my examination or treatment neccessary to establish a health insurance claim for payment.
 
I understand that occasionally my insurance company will deny payment for services that my physician and/or I feel are necessary for my good health. I hereby agree to pay for such services in a proper and timely manner.
 
__________________________                 ________________________________________________________________
Date   Signature   ( Self, Parents, Guardians, Others )