Mission Family Medical Group Last Name

First Name

Address Home Phone

Work Phone

Emergency Contact

MI

Birth Date

Today’s Date

City

State

Zip Code

Mobile Phone

Sex

Acct #

Emergency Contact Phone #

PLEASE COMPLETE THE FOLLOWING SECTION IF GUARANTOR IS DIFFERENT FROM PATIENT Last Name

First Name

Address Home Phone

Work Phone

MI City

State

Zip Code

Mobile Phone

Birth Date

Gender

PRIMARY INSURANCE

SECONDARY INSURANCE

Insurance Name

Insurance Name

Claims Address

Claims Address

City, State, Zip

City, State, Zip

Subscribers Name

Relationship to Patient

Gender M F

Subscribers Name

Group No.

ID#

Group No.

Subscribers Birth Date

Subscribers Birth Date

Effective Date

Patient’s Relation to Subscriber:

Patient’s Relation to Subscriber:

ID #

Self

Spouse

Child

Patient Co-Pay / Deductible: _______________

Other

Gender M

Self

Spouse

Amount Received today: _______________

Child

Credit Card

F

Other

Check

I authorize the release of any medical information necessary to process medical insurance claims for services rendered. I understand and agree that I am ultimately responsible for payment.

SIGNED________________________________________________________________ DATE ____/_____/_____

Cash

MISSION VIEJO FAMILY MEDICAL GROUP, A MEDICAL CORPORATION 26732 Crown Valley Pkwy Suite 461 Mission Viejo, CA 92691 949-347-2566 HOW MAY WE CONTACT YOU? We need to know how you would prefer to be contacted with your medical information. Please check all that apply: Home telephone: PH#

Yes

Message on home answering machine?

Yes

Work telephone: PH#

ext.

Message on work voicemail?

Yes

Cellphone: PH#

No

No

Yes

No

Yes

No

No

Message on cellphone voicemail?

Written communication?

Yes

No

Mailing Address May we have a conversation releasing your medical information with a family member or emergency contact? Yes

No

Please specify the persons allowed to receive medical information:

Name

Phone number

Relationship

Name

Phone number

Relationship

Patient Signature

Print Name

Date

You may modify this list at any time by presenting your request in writing to our office.

MISSION VIEJO FAMILY MEDICAL GROUP, A MEDICAL CORPORATION AUTHORIZATION FOR DISCLOSURE OF CONFIDENTIAL INFORMATION I hereby authorize and request: Dr.:

(please include first and last name)

Address: Phone: Fax: to furnish information or copy of my medical records (paper only, disc not accepted) to:

Dr. David R. Gonzalez 26732 Crown Valley Parkway, Suite 461 Mission Viejo, CA 92691 Phone 949-347-2566 · Fax 949-347-1606 Medical findings and treatment about my illness and/or treatment during the period from to

.

I understand that this is a required consent and I must voluntarily and knowingly sign this authorization before any records may be released and that I may refuse to sign, but in that event the records will not be released. I further release my physician from liability arising from the release of information to the individual(s)/agency designated herein. Print Name

Date of Birth

Signed

Witness

Address

Date