services needed: drug screen alcohol testing injury care

services needed: drug screen alcohol testing injury care

WORK WELLNESS
1801 COLORADO AVE SUITE 130 TURLOCK, CA 95382
TELEPHONE (209) 216-3333 FAX (209) 216-3330
PATIENT REGISTRATION SHEET
LAST NAME/APELLIDO __________________________FIRST NAME/NOMBRE____________________
ADDRESS/DOMICILIO_____________________________________________________________________
CITY/CIUDAD___________________________STATE/ESTADO______ZIP/ZONA POSTAL____________
TELEPHONE/TELEPHONO____________________________
SEX _________ DATE OF BIRTH/FECHA DE NACIMIENTO___________________________
SOCIAL SECURITY#/SEGURO SOCIAL _____________
EMPLOYER’S INFORMATION
EMPLOYER NAME ______________________________________________________________________
EMPLOYER ADDRESS _________________________________CITY_____________________________
TELEPHONE
SERVICES NEEDED:
FAX _________________CONTACT___________________________
□ DRUG SCREEN
□ ALCOHOL TESTING
□ INJURY CARE
INJURY INFORMATION
DATE OF INJURY/FECHA DE LASTIMADURA ____________________
DESCRIBE HOW THE ACCIDENT HAPPENED/ESPLIQUE COMO PASO EL ACCIDENTE:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
I hereby authorize the release of any medical information to insurance carriers to process a claim and request
payment either to myself or to Work Wellness/Romeo Medical Clinic for medical services rendered. I
UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER
OR NOT COVERED BY MY INSURANCE.
Yo doy consentimiento para que el seguro obtenga informacion sobre mi expendiente para procesar mi caso y
obtener pagos para mi o para Work Wellness/Romeo Medical Clinic por servicios medicos recibidos. Yo
entiendo que soy responsible por todos mis cargos si no los cubre mi seguro.
SIGNATURE/FIRMA___________________________________________________DATE______________
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