Patient Information:

Meaningful Use Verification:

Responsible Party: (If other than above, when patient is under 18 years old)
{Please note – Anyone over the age of 18 years old is financially responsible for their own statements}

Primary Insurance:

Insurance Subscriber Information:

Secondary Insurance:

Insurance Subscriber Information:

Emergency Contact: NOT AT THE SAME ADDRESS AS PATIENT

Are you being seen today for a work or auto related accident? YES or NO

All charges are due at the time of service. All services rendered are charged to the patient or their responsible party. I understand that I am responsible for any amount not covered by my insurance. Therefore, I hereby authorize the doctors of Oklahoma Otolaryngology Associates to furnish information to insurance carriers concerning my illness and treatment. The information authorized for release may include information which may be considered a communicable or venereal disease, including hepatitis, syphilis, gonorrhea, HIV and AIDS. I assign to the physician(s) all payments for medical services rendered to myself.