LACY MEDICAL SERVICES, LLC PLEASE COMPLETE AND PROVIDE THE RECEPTIONIST WITH PICTURE ID AND INSURANCE CARDS. Por favor, complete y revuelve a la recepcionista con identificación y tarjetas de seguranza. PATIENT NAME/ Nombre: ____________________________________ DATE/ Fecha: _________________ SOCIAL SECURITY #/Seguro Social ___________________________ D.O.B./Fecha de Naci. _________ ADDRESS/Dirección ________________________________________________________________________ CITY/Ciudad_____________________________ STATE/Estado_____________ ZIP/Código ____________ TELEPHONE: HOME/Teléfono casa _____________________ CELL/Trabajo o celular ____________________ EMAIL ADDRESS/Correo electrónico: ____________________________________________________________ INSURANCE/Seguro de salud: ______________________________________________________________ ANY NEW INJURIES SINCE YOUR LAST VISIT? / ¿Alguna lesión nueva desde la última cita? ____________________________________________________________________________________________ HOW DID YOU HEAR ABOUT OUR OFFICE? / ¿Como se oyó sobre la oficina? ____________________________________________________________________________________________ ____________________________________________________________________________________________ LACY MEDICAL SERVICES, LLC PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary to process this claim. I authorize payment of medical benefits to the undersigned physician or provider for services described below. I also request payment of government benefits either to myself or to the party who accepts assignment below. I also, am aware that any bills that are accrued if not paid by my insurance company or third party institution are my responsibility and I agree that I will pay the due amount, if any, in a timely manner. Additionally, I understand that if I do not pay the amount due or make an agreement with the office of a payment plan, the bill will be subject to outside collection and/or credit reporting. SIGNED ________________________________Patient Provider: Lacy Medical Services, LLC (R.100914) DATE _______________________