PD ROM 1/PD ROM Volume I - Macintosh Software from BMUG (1988).iso/Business/FileMaker Templates/Med Ins Form

FileMaker Pro Database | 1986-11-06 | 15.5 KB | 188 lines | [FMKD/FMKR]

HBAM2001MAY84
2-1.00F
2.00I
MedicareB
MedicaidB
ChampusB
ChampVAB
FECA Black LungB
OtherB
Patient's Name(L,F,M)B
Pt's Date of BirthB
Insured's Name(L,F,M)B
Patient's AddressB
MaleB
FemaleB
Insured's ID No.B
SelfB
SpouseB
ChildB
Other RelationB
Insured's Group No.B
Employee Hlth PlanB
Other Hlth InsuranceB
10.YesB
10.NoB
10b.AutoB
A    10b.OtherB
Insured's Address
Insured's TelB
11a.ActiveB
11a.RetiredB
11a.DeceasedB
11a.Branch of ServiceB
Date of llnessB
IllnessB
Date first consultedB
Dates of Similar IllnessB
%A    EmergencyB
Date PT return workB
Date tot. disabil: fromB
Date tot. disabil: throughB
Date part. disabil: fromB
Date part. disabil: throughB
Name of Refer. Phy./SourceB
Hosp Serv; Adm.B
Hosp Serv; Disc.
Name/Add. Serv. Rend.B
22Lab: YesB
3A    22Lab: NoB
22Lab ChargesB
23.1DiagnosisB
DX CODE
23B. EPSDT YesB
23B. EPSDT NoB
Prior Auth. No.B
24.1 Date Serv-FromB
24.1 Date Serv-ToB
24B.1 Place ServB
24C.1 DescriptionB
    CPT.File+
24D.1 Diag CodeB
Charges E1B
    CPT.File+
DaysUnits F1B
TOS G1B
Assignment-YesB
Assignment-NoB
Total ChargeB
sum (CHARGE EF1)F
Amount PaidB
Balance DueB
Total Charge-Amount PaidF
Patient's Acct No.B
Proc Code 1B
Attorney's NameB
Tel. No.B
Employer's NameB
Employer's AddressB
Marital status-MarriedB
Marital status-SingleB
Marital status-otherB
Pt's Tel No.B
Parents or SpouseB
Insurance Co. NameB
Soc Sec NumberB
CHARGE EF1B
Charges E1 * DaysUnits F1F
710-13
Robert J Varipapa, MD
577-68-7739
31 Gooden Ave
Dover, DE 19901-4171
51-0290071
[phone]
Other
Medicare
Medicaid
Champus
ChampVA
Patient's Name(L,F,M)
Pt's Date of Birth
Female
Insured's Name(L,F,M)
Patient's Address
Spouse
Child
Other
Insured's ID No.
    Group No.
Employee Hlth Plan
Other Hlth Insurance
Assignment
Work-Related?
    Accident?
Other
Champus Sponsors
Insured's Address
Active
Deceased
Retired
Insured's Tel
Branch of Service
Date of llness
Date first consulted
Name of Refer. Phy./Source
Hosp Serv; Adm.
discharged
Place
Descrip
Unit Charge
    Diagnosis
Total Charge
Amount Paid
Balance Due
Cofidential Medical Information
Robert J. Varipapa, MD
31 Gooden Avenue
Dover, DE 19901-4171
Tel [phone]
Patient's Name
___________________________
@Last                        First                             MI
Soc Sec Number
Patient's Address
Patient's Tel. No.
 Date of Birth
Parents or Spouse
Female
Marital status:  Married
Single
Other
Insurance Information
PPlease give name of insurance company which will be paying for charges incurred.
TIf this is a Workmans Compensation Case, please give Workmans Compensation Insurance
Company's name first.
Insurance Co. Name
Policy number
    Group No.
Policyholder's Name
@Last                        First                             MI
 Address
 Telephone No.
;Is subscriber employed and covered by Employee Health Plan?
#Patient relationship to subscriber:
Spouse
Child
Other Relation
Other Health Insurance:
%Was condition related to an accident?
Other
.Was condition related to patient's employment?
Referral Information:
Referring Physician
or person:
9If case refers to a legal situation, who is the attorney?
Address ___________________
Tel. No.
Employment Information:
Employer's Name
Employer's Address
AUTHORIZATION FOR PAYMENT:
[       I hereby authorize payment directly to Robert J. Varipapa, MD for the medical and/or
Vsurgical benefits, if any, otherwise payable to me for services rendered, based on the
Zcharges for these services.  I have discussed these charges with either Dr Varipapa or his
[staff and I understand that I am financially responsible for these charges. I authorize Dr.
SVaripapa to obtain information from my inpatient and/or outpatient medical records.
5Date____________ Signed______________________________