Scherl, Chessler, Zingler & Spinnell, M.D. P.A.

	Exam Prep/Info
	Patient Info Form
	Insurance Plans
	Emergency Procedure

Patient Information Form
Fill out our patient information form below and click “Open Print Preview”. In the print preview window, select the print option from the file menu above and print the document.

When you come to your first office visit, you should bring this completed form with you to expedite our process.

When you have completed this form, select the print preview button below to open the print preview screen.

Date:
Primary care physician:
Patient's name:
S.S.#:
Sex:
Date of birth:
Age:
Marital status:
Address:
City:
State:
Zip code:
Home phone:
Work phone:

Employer:
Occupation:
Address:
City:
State:
Zip code:

Emergency contact:
Phone number:
Relation:

Insured's name:
S.S.#:
Date of birth:
Age:
Work phone:
Employer:
Occupation:
Address:
City:
State:
Zip code:

PLEASE READ: ALL CO-PAYS AND REFERRALS MUST BE GIVEN TO THE RECEPTIONIST PRIOR TO YOUR EXAM. YOU ARE RESPONSIBLE FOR ALL SERVICES NOT COVERED BY YOUR INSURANCE PLAN.
Payment method:
Primary insurance carrier:
PIC Policy holder:
Secondary insurance carrier:
SIC Policy holder:
INSURANCE AUTHORIZATION AND ASSIGNMENT: I REQUEST THAT PAYMENT OF AUTHORIZED MEDICARE/OTHER INSURANCE BENEFITS BE MADE TO ME OR ON MY BEHALF TO DR'S SCHERL, CHESSLER, ZINGLER, & SPINNELL FOR ANY SERVICES RENDERED TO ME BY THAT PARTY WHO ACCEPTS ASSIGNMENT. I AUTHORIZE ANY HOLDER OF MEDICAL OR OTHER INFORMATION ABOUT ME TO RELEASE TO THE SOCIAL SECURITY ADMINISTRATION AND HEALTHCARE FINANCING ADMINSTRATION OR ITS INTERMEDIARIES OR CARRIERS ANY INFORMATION NEEDED FOR THIS OR ANY OTHER RELATED CLAIM. I PERMIT A COPY OF THIS AUTHORIZATION TO BE USED IN PLACE OF THE ORIGINAL AND REQUEST PAYMENT OF INSURANCE BENEFITS TO EITHER MYSELF OR TO THE DOCTOR. I UNDERSTAND THAT IT IS MANDATORY TO NOTIFY THE HEALTHCARE PROVIDER OF ANY OTHER PARTY WHO MAY BE RESPONSIBLE FOR PAYING FOR MY TREATMENT.
Signature:	To be filled out on printed form
Date:	To be filled out on printed form

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1555 Center Avenue Fort Lee, New Jersey 07024
T: 201-945-6564 FAX: 201-461-9038