Patient Information Sheet

Call Today:

Cliffside Park: (201) 945-6747
Hours Open:

Mon–Fri: 8:00 AM to 9 PM
Sunday: 8:30 AM–5:30 PM

PATIENT BILLING INFORMATION
Name*
First Name Last Name
Gender*
- Male
- Female
Patient's Address*
Patient's Address City State Zip
Home Phone#*
Work Phone#*
Social Security#
1 2 3
Date of Birth*
Social Status*
- Single
- Married
- Divorced
- Widowed
- Separated
Insured's Name
Gender
- Male
- Female
Insured's Address
Insured's Address City State Zip
Insured's Home Phone#
Date Of Birth
Insured's Relationship To Patient
Date Of Injury/Accident*
Type Of Coverage
- PIP
- W/C
- Health Ins.
- Lien
Auto Insurance Name
Insurance Address
Insurance Address City State Zip
Policy#
Claim#
PIP Adjuster's Name
Phone#
X#
Health Insurance Name
Phone#
Insurance Address
Insurance Address City State Zip
Insured's ID#
Policy/Group#
Effective Date
If health coverage is not available, please sign
Attorney's Name
Attorney's Address
Attorney's Address City State Zip
Phone#
Fax#
For Office Use Only!
Utilization Company's Name
Phone#
Fax#
Authorization Status
- Authorized
- Not Authorized
- No Response
- Not Required
Sign Here for 1st visit
I HEREBY AUTHORIZE CLIFFSIDE PARK IMAGING & DIAGNOSTIC CENTER, L.L.C. TO RELEASE ANY INFORMATION REGARDING SERVICES RENDERED BY THEM AND ALLOW A PHOTOCOPY OF MY SIGNATURE TO BE USED TO FILE INSURANCE CLAIM. I ALSO HEREBY AUTHORIZE AND DIRECT PAYMENT FOR BENEFITS DUE ME FOR THE SERVICES PROVIDED BYCLIFFSIDE PARK IMAGING & DIAGNOSTIC CENTER, L.L.C. TO BE MADE DIRECTLY TO THEM REGARDLESS OF MY INSURANCE BENEFITS. PHOTOCOPIES OF THIS AUTHORIZATION SHALL BE CONSIDERED AS EFFECTIVE AND VALID AS THE ORIGINAL. I UNDERSTAND I AM FINANCIALLY RESPONSIBLE FOR THE FEES FOR SERVICES RENDERED.
1st Visit - PATIENT’S SIGNATURE
1st Visit - Date
2nd Visit - PATIENT’S SIGNATURE
2nd Visit - Date
3rd Visit - PATIENT’S SIGNATURE
3rd Visit - Date

Patient Information Sheet

PATIENT BILLING INFORMATION

For Office Use Only!

Sign Here for 1st visit