Windsor Imaging Center

Patient Information Form

Patient Information

Date:
Patient Weight:
Patient Name:
Patient SSN#:
Sex:
Age:
Date of Birth:
Marital Status:
Address:
City:
State:
Zip Code:
Telephone:
Referring Physician:

Additional Information

Out of State Address:
State:
Zip Code:
Patient Employer:
Patient Occupation:
Business Phone:
Spouse Name:
Nearest Relative (not living in household):

Illness | Injury Information

Is your illness or injury due to:
Date of the accident:
Attorney Name:
Attorney Phone:
Do you authorize Windsor Imaging to send all financial information to the Attorney named above?

Insurance Information: (Must have insurance card)

Insurance Company:
Address:
Phone:
ID:
Group:
Policy #:
Insured:
Relation to Insured:

2nd Insurance Company Information:

Insurance Company:
Address:
Phone:
ID:
Group:
Policy #:
Insured:
Relation to Insured:

AUTHORIZATIONS:
I hereby authorize Windsor Imaging to release any information acquired in the course of my treatment to my insurance company. I request that payment of authorized benefits be made either to me or on my behalf for any services furnished me by Windsor Imaging. (MEDICARE PATIENTS) I authorize any holder of medical or other information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits for related services.

List of Services:

Patient Services:

Patient Information Form