Dr. Hazenfield -- Ear, Nose, and Throat Doctor in Hawaii

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NEW PATIENT

Billing and Insurance Information

PRE-APPOINTMENT FORM

for

Hugh N. Hazenfield, M.D., F.A.C.S.

You may fill out this form to save yourself time when you arrive at the office.

Please complete and send at least 3 working days prior to your appointment.

(This is for your convenience - it is not required.)

Privacy Note: This information is forwarded directly only to Dr. Hazenfield and the Office Manager, Michelleen Graham. After receipt, it will be given to the office staff for data entry into our computer.

Please use your "Tab" key to navigate to next field.

Do not hit "Enter" key until you have completed the form.

Your Appointment Date (Required):

Last Name:

First Name and Middle Initial:

Date of Birth (Required): Patient's Soc. Sec. No:

Patient's Age: Years Months

Gender: Marital Status:

Mailing Address (Include Apt. #):

City: State: Zip: Country:

Home Phone: (Check here if you have Caller ID)

Work Phone: Ext.

Cell or Pager: E-Mail:

Emergency Contact Name:

Phone: Relationship:

Employer:

Employer's Telephone:

Guarantor (Responsible for Insurance or Payment): Self Other

Only if you checked "Other", complete this Guarantor information:

Guarantor Name: Relationship:

Guarantor's Soc. Sec. No. Guarantor's Birth Date:

Guarantor's Phone: Home: Work:

Guarantor's Mailing Address:

City: State: Zip:

Your Insurance Information:

Primary Insurance Company:

Subscriber's Name:

Membership Number: Group No.:

Secondary Insurance Company (if any):

Subscriber's Name:

Membership Number: Group No.:

(If you have more than 2 insurance companies, you may provide that information at the time of your visit.)

Who referred you?

Mahalo!

When you come to the office, you will not need to fill out the Insurance Information Sheet.

You will still need to complete or sign the following forms:

Health History Form(s) (You may download these from this website and complete prior to your visit.)

Authorization to Pay Insurance Benefits to Physician

Authorization to Release Information

Acknowledgement of Receipt of Welcome Brochure

List of individuals who may have access to your medical information (if any)

Acknowledgement of Receipt of Privacy Notice (HIPAA requirement)

Press SUBMIT button below to send information to Dr. Hazenfield.

Press RESET button if you want to clear the form and start over.

(If you get a message "Internal server error", please try hitting the "Submit Form" button again. Your registration information is coming through even if you get an error message.)

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