By filling out this form
you do not have to arrive 15 minutes early to fill out it in our office.
This gives you the opportunity to fill out the form in the privacy
of your own home, and gives you access to your medical records.
Mail:
Fax:
Online:
Fill
out this form, and then print it,
sign it and mail it to:
Bernard L. Rosenfeld, M.D., Ph.D.
7400 Fannin, Suite 910
Houston, TX 77054
Fill out this
form, and then print it,
sign it and fax it to 713-790-0527.
Fill out this
form and press Submit
Form. You do not have to sign it
because your e-mail address is
your signature.
Patient
Name
Phone
Address
City,
State, Zip
Date
of Birth
Age
Marital
Status
Race
Employer
Business
Phone
Occupation
Spouse
Data
Spouse's
Name
Occupation
Employer
Business
Phone
Person
Responsible for Bill Data
Name
(if other than above)
Phone
Address
City,
State Zip
Relationship
Nearest
Relative Data (Not living with patient)
Nearest
Relative
Phone
Relationship
Referral
Data
Referred
By
Phone
Insurance
Data
Insurance
Company
Policy
Number
Member
Name
Group
Number
Employer
Insurance
Phone
Insurance
Mailing Address
City,
State Zip
Secondary
Insurance Data
Insurance
Company
Policy
Number
Member
Name
Group
Number
Employer
Insurance
Phone
Insurance
Mailing Address
City,
State Zip
Authorization
to Release Information and to Pay Benefits
I hereby
authorize Bernard L. Rosenfeld, M.D., Ph.D. who has treated
or attended me or my dependents
to furnish any medical information requested. In consideration
for services rendered, I hereby transfer and assign to Dr. Rosenfeld
who has treated me or my dependent, and benefits of insurance
that I may have.
I am responsible for paying non-covered services. A photocopy
of this authorization shall be considered
as effective and valid as the original.
Patient
SSN
Spouse's
SSN
Medicare
Number
Medicaid
Number
Texas
Driver's License
Signature
________________
Do
you have an appointment?
Yes
No
If
yes, when?
If
no, would you like for us to contact you regarding an appointment?
Yes
No
How
would you like to be contacted?
How
did you find this web site?
Read
and Sign
I
acknowledge that the above information is correct and complete.
Your signature
_____________________________________________
Today's date
_____________________________________________
E-Mail Address
Instructions
Now that your Personal Data is complete you must enter
you Personal Medical History.
If you elected to Mail or Fax your Personal Data then
print and sign this form and press "Go To Step Two".
If you elected to register Online then press "Go
To Step Two".
Spouse
Data
