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How Did You Hear About Us?
• • •
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Doctor or Friend's Name:
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Height (inches):
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Weight (pounds):
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STAFF USE ONLY-
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BENEFITS AND ELIGIBILITY
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CARRIER
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PAYER ID #
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MEMBER ID #
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PLAN HOLDER:
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IF FAMILY (ENTER THE BELOW INFO - READ ONLY)
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NAME
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DATE OF BIRTH
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RELATION TO PATIENT
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ADDRESS
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NETWORK STATUS:
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DATE OF SERVICE
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EFFECTIVE DATE:
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DEDUCTIBLE:
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DED/MET (IN – NETWORK)
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DED/MET (OUT-NETWORK)
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COPAY FOR OFFICE VISITS:
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COPAY FOR PROCEDURES:
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REFERRAL FOR SPECIALIST VISIT?
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AUTHORIZATION FOR PROCEDURE?
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REF # & REP NAME:
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NYGE STAFF:
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NOTES:
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