SOUTHERN NEVADA SURGERY SPECIALISTS
	ASSOCIATED SURGICAL GROUPS

	PATIENT INFORMATION

NAME ___________________________________________________________________________
		(LAST)				(FIRST)			(MIDDLE INITIAL)
SS# _______________________________________  DATE OF BIRTH _____________________
ADDRESS ________________________________________________________________________
CITY ______________________________________  STATE ____________  ZIP ___________
HOME PHONE ________________________________  REFERRED BY _______________________
EMPLOYER __________________________________  WORK PHONE ________________________
EMPLOYER ADDRESS _______________________________________________________________
MARITAL STATUS ____________________________  SPOUSE'S NAME _____________________
EMERGENCY CONTACT (OUTSIDE YOUR HOME) __________________________________________
PHONE _____________________________________  RELATIONSHIP ______________________

	PRIMARY INSURANCE

INSURANCE COMPANY _________________________  PHONE _____________________________
ADDRESS ________________________________________________________________________
NAME OF POLICY HOLDER _____________________  DATE OF BIRTH _____________________
SS# _________________  POLICY # ___________  GROUP/LOCAL _______________________
EMPLOYER/RETIRED FROM _____________________  OCCUPATION ________________________
WORK PHONE ________________________________  CO-PAY OR % DUE ___________________
IS THIS A WORK RELATED INJURY _____________  DATE OF INJURY ____________________

	SECONDARY INSURANCE

INSURANCE COMPANY _________________________  PHONE _____________________________
ADDRESS ________________________________________________________________________
NAME OF POLICY HOLDER _____________________  DATE OF BIRTH _____________________
SS# _________________  POLICY # ___________  GROUP/LOCAL _______________________
EMPLOYER/RETIRED FROM _____________________  OCCUPATION ________________________
WORK PHONE ________________________________  CO-PAY OR % DUE ___________________

	FINANCIAL RESPONSIBILITY ACKNOWLEDGMENT

As a service to our patient, we will submit billing for all services rendered.  The patient/insured is responsible for knowing his or her co-payment and/or deductible.  The patient/insured is responsible for knowing the providing facilities that his or her insurance company requires use of.  If the patient requires any additional testing to be performed outside of this office, please advise us of the facilities you may use so a proper referral can be given.  All co-payments and/or deductibles are required to be paid at the time of service.

I hereby authorize release of information necessary to file a claim with my insurance company, and assign benefits to Southern Nevada Surgery Specialists/Associated Surgical Groups.  I understand that I am financially responsible for any balance not covered by my insurance carrier.

CASH PATIENTS - Payment is due at the time of service, unless other arrangements have been made.

I have read and understand the above statements.


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Signature of Patient/Responsible Party						Date


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Signature of Patient/Responsible Party						Date