Richard D. Franco, M.D.
Matthews W. Gwynn, M.D.
Keith A. Sanders, M.D.

Welcome to our office
Atlanta Neurology, P.C.
Date: ________________________
Account #: ____________________

Lisa H. Johnston, M.D.
James M. Kiely, M.D., Ph.D.
Sharon D. King, F.N.P.-C

PATIENT INFORMATION

Title Name First MI Last

Address City State Zip

Home Phone Work Phone S.S.#

Birthdate Age Sex:M F Marital Status SGL M D SEP

Spouse's Name Home Phone Work Phone

Patient's Employer Patient's Occupation

Address City State Zip

Local Relative or Friend Phone

Address City State Zip

INSURANCE INFORMATION

Primary Insurance Company Phone

Address City State Zip

Insured's Name I.D.# Group#

Secondary Insurance Company Phone:

Address City State Zip

Insured's Name I.D.# Group#

Medicare Number Medicaid Number

Referring Doctor:

IS POLICYHOLDER OTHER THAN SELF? IF SO, PLEASE COMPLETE BELOW:

PRIMARY INSURANCE

SECONDARY INSURANCE

Policyholders Name (First)	M.I.	Last	Relationship: (Check One) Spouse, Parent, Other
SS#: DOB:
Home Phone Work Phone
Employer

I authorize any holder of medical or other information about me to release to my insurance company or to the Social Security administration and Health Care Financing administration or its intermediaries or carrier any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or the party who accepts assignment. Regulations pertaining to medical assignment of benefits apply.

Signature _____________________________________ Date ______________________