Patient Intake Form: Patient Registration

"*" indicates required fields

MM slash DD slash YYYY
Local Address
Out of State Address
Name of Responsible Party (if patient is a minor)
Assignment of Benefits - Confirmation
I hereby assign, transfer and convey all medical benefits to be paid directly to PASWFL - Dr. Robert W. Pollack and recognize it is my responsibility to pay for all non-covered services. I also authorize PASWFL to release any information necessary to process an insurance claim. In the event the patient is a minor, a parent or guardian who will be responsible for the payment of the bill must accompany the patient. A photocopy of this Assignment will be considered as valid as the original.
Assignment of Benefits - Date of Signature