ROHNA
PROFESSIONAL OTOLARYNGOLOGY ASSOCIATES
A DIVISION OF REGIONAL OTOLARYNGOLOGY HEAD AND NECK ASSOCIATES, LLC
HEAR MD
Emilio A. Roncace, MD, FACS, James M. Sumerson, MD, FACS, Stephen P. Gadomski, MD, FACS,
Samir Shah, MD, FACS, Anthony Cultrara, MD, Ashmit Gupta, MD, MPH, Harry Cantrell, MD, FACS
Last Name__________________________ First Name ___________________ Initial _____ Date___________
Street ______________________________ Apt/Bldg ______________________________________________
City, State, Zip _____________________________________________________________________________
Phone Home ( ____) _________________ Work ( ____) __________Ext. ______ Cell (____) _____________
Sex M ____ F ____ Birth date _______________ Age _____ Marital Status S__ M __ W__ D__
Social Security No. ________________________________ Employed Yes _____ No ______
Name of Employer __________________________________________ Phone # (____)___________________
Spouse’s Employer __________________________________________ Phone # (____)___________________
If patient is a minor, parents employer ___________________________ Phone # (____)___________________
Referred by_______________________________ Family doctor _____________________________________
Phone ___________________________________ Phone ___________________________________________
Address __________________________________Address _________________________________________
Do you want above doctor/doctors to receive a copy of this visit Yes ___ No ___ (Managed care companies usually require one)
Nearest relative NOT living with you ___________________________________________________________
Relation __________________________________________Phone # (____)____________________________
Preferred Pharmacy _________________________________Phone # (____)____________________________
Insurance Company Name ___________________________ Subscribers Name _________________________
Insurance I.D. # ____________________________________
Subscribers Birth date _______________________________Social Security No. ________________________
Employer _________________________________________Phone # (____)____________________________
Second Insurance Company Name _____________________________________________________________
Insurance I.D.# ______________________________________
Subscribers Name __________________________________________________________________________
Subscribers Birth date _______________________________Social Security No. ________________________
Employer _________________________________________Phone # (____) ___________________________
If patient is a minor please complete the following financial responsibility
Name ____________________________________________________________________________________
Address if different from patient _______________________________________________________________
_________________________________________________ Phone # (____)____________________________
Relation to patient __________________________________________________________________________
Do you or the patient have a living will or advance directive Yes _____ No _____
PLEASE READ and SIGN: I understand and agree that I am ultimately responsible for payment of any balance not covered by medical insurance. I certify that the information I have given is true and correct to the best of my knowledge, and I will notify you of any changes in my health status or in the above information.
I authorize release of any medical information necessary to process all claims and I authorize payment of medical benefits for services rendered by Professional Otolaryngology Associates. I further authorize release of medical information requested by another treating physician or health institution to assist in my ongoing care. I understand that some of the information released may contain but is not limited to sensitive material with regard to alcohol and drug abuse, sexually transmitted disease, behavior or mental health, HIV/AIDS, hepatitis, or other communicable diseases.
Signature _________________________ Date _______________