Offering leading edge reproductive technology with unsurpassed patient service
Patient Forms
THECENTER FOR REPRODUCTIVE HEALTH
508 W Sixth Avenue, Suite 500, Spokane, WA 99204 (509) 462-7070 or (800) 334-1409
Edwin D. Robins, MD; Debbie Little, ARNP
FEMALE PATIENT INFORMATION
(Legal) Name: ______________________________________________________________Date of Birth: ____________
(First) (Middle) (Last)
Address: __________________________________________________________________________________________
(Street) (City) (State) (Zip Code)
Home phone: (_____)______________________________ Social Security #: ______________________________
E-Mail Address: ___________________________________
Patient employer: __________________________________ Occupation: ___________________________________
May we contact you at work? Yes No Work Phone #: _______________________________________
REFERRAL INFORMATION
OB/GYN Physician: ____________________________ Phone #: ______________________________
Did your OB/GYN refer you to our office (YES or NO) Please Circle
If NO, who referred you to CREF: ___________________________________________
INSURANCE INFORMATION
Patient’s Primary Insurance Carrier Patient’s Secondary Insurance Carrier
Insurance Co: Insurance Co:
Address: Address:
Phone#: Phone#:
ID#: ID#:
Group #: Group #:
Subscriber: Subscriber:
Are you covered under your spouse/partner’s Insurance Plan? (YES or NO) Please circle
AUTHORIZATIONS: I authorize the undersigned medical providers to release any information in the course of my examination or treatment to my insurance company. I further authorize any benefits due for service rendered to be paid directly to Edwin D. Robins, MD, PS. I understand that if the physician’s fees DO NOT meet my insurance carrier’s customary and reasonable fee, I will therefore, be responsible for any balance due after insurance payments. I am financially responsible for any balance due, including services exceeding the limitations of my insurance policy.
COPY OF INSURANCE
SIGNATURE: ______________________________DATE ___________ CARDS & ID
NOTE: In order to control our costs, we request that office visits or copayments are to be paid at the time service is
rendered. We would rather control our billing costs than to be forced to raise our fees.
Please indicate below how you wish to pay for your serrvices.
CASH PERSONAL CHECK MC VISA
O/chad//scheduling/cref np demo. Rev 11/2005ml
Coming Soon
Scheduling
For appointments call 509.462.7070 or 800.334.1409
