Patient Identification

Home Phone
Home Phone
Cell Phone
Cell Phone
Address *
Address
Work Phone
Work Phone
Emergency Contact's Address *
Emergency Contact's Address
Emergency Contact's Home Phone *
Emergency Contact's Home Phone
Emergency Contact's Work Phone *
Emergency Contact's Work Phone
Emergency Contact's Cell Phone *
Emergency Contact's Cell Phone

Medical Information

Release of Information

Date *
Date
Release *
I authorize the release of any medical information necessary to process my medical bills. I permit a copy of this authorization to be used in place of the original.
Authorization *
I authorize Shahzada, Green, Thomson, MD's and Ziegler, APRN at South Central Kansas Clinic, LLC to apply for benefits on my behalf for covered services rendered by any one of them. I request that payment from my insurance company be made to South Central Kansas Clinic, LLC.
Certification *
I certify that the information I have reported is correct. I understand that I am responsible for any amount not covered by my insurance and that payment arrangements must be made before services are rendered.

Spouse or Parent Information (if under 18)

Emergency Contact?
If your emergency contact (completed on the patient information form) is your spouse or a parent, you do NOT need to duplicate their information below. FOR PATIENTS UNDER 18 - You will still need to complete the information below for the parent who is NOT your emergency contact.
Name of parent is required for patients under the age of 18.
Spouse Address
Spouse Address
Spouse Phone
Spouse Phone
Spouse Work Phone
Spouse Work Phone
Father's Address
Father's Address
Father's Phone
Father's Phone
Mother's Address
Mother's Address
Mother's Phone
Mother's Phone