Date: TA rj • I 1)a-IDICI
Date: TA rj • I 1)a-IDICI
MITCHELL A KLINE E
PATIENT REGISTRATION
NAME: J e
SOCIAL SECURITY: -53 DATE OF BIRTH1- 2O GENDER 1.\-4
PREFERRED LANGUAGE: I; ICI ‘L1SH Marital Status:eM D W
AMERICAN INDIAN OR ALASKA NATIVE ASIAN BLACK OR
AFRICAN AMERICAN NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
ETHNIC GROUP:
HISPANIC OR LATINO NOT HISPANIC OR LATINO UNKNOWN
ADDRESS: ei CAST ST
CITY: NI aVV Nh3114-...
HomFis ,41 o tqr
CELL# a I a - 53R _ 3-4-39
PHARMACY NAME VI TA t4 EA cm
PHONE#_ISTATE: N y ZIP CODE local
WORK# - cat) -q C4
E-MAIL jetAtaCartionaOyncial.C.Din
ADDRESS 1,a1S-- `ST Ave •
FAX* (e
OCCUPATION/EMPLOYER: ZE2iarar. /4 -71z etcYr CAO.
REFERRED BY: (PHYSICIAN, PATIENT, FRIEND, OR OTHER) PLEASE CIRCLE AND LIST
NAME:
SPOUSE/PARENT:
FINANCIAL/INSURANCE INFORMATION
Pr Kline does not narticipate with am health insurance. I understand that I am responsible for all chargers incurred
and that payment is due at the time services are rendered. We require a copy of your insurance card for laboratory
purposes only.
I request that payment of authorized Medicare benefits be made either to me or on my behalf to Mitchell Kline. M.D.
for semices furnished to me by the provider. I authorize any holder of medical information about me to release to CMS
and its agents any information needed to be determine these benefits payable for relatrrl sen ler%
CARRIER NAME: LI $ 1-th I-I-GAL-TVCAIZE.7 ID#
GROUP (O OS
Employer Sponsored? Government Sponsored? —
RELATIONSHIP TO INSURED NAME: S ei%
KINDLY GIVE 211IR HOURS NOTICE TO CANCEL APPOINTMENTS.
A FEE OF SI00.00 WILL BE BILLED TO YOU FOR LESS THAN 24HOUR HOURS NOTICE AS WELL AS
FAILURE TO KEEP SCHEDULED APPOINTMENTS.
EFTA00314094