DOWNLOAD PDF
Spouse Information
Responsible Party (If other than patient please fill in below):
Emergency Information:
Please note that we now require a copy of your Medicare, Medicaid and or Insurance Card to verify the mailing address, phone number and the spelling of your name as shown on each individual card. We can not file insurance claimes for you without the birthdate and social security number of the policy holder. We are also requiring a copy of your driver’s license or other picture id that includes your signature. This is to be able to verify your identity in the event of requests for release of Private Health Care information. We appreciate your help and understanding of these requests.
Primary Insurance Information:
Supplemental Insurance Information:
Authorization and Financial Understanding:
I hereby give my permission for any employee of Wyoming Surgical Associates, PC as well as any physician’s office or facility to which I may be referred to contact me at: