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| Home Page | Case Examples | Qualifications | |
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Please print and fill out this questionnaire. Mail or fax it to Donald Linker, M.D., 909 Montgomery St., #600, San Francisco, CA 94133. Fax: (415) 331-3563 |
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Patient Name:
Last First Middle |
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| How would you like to be addressed? | |
| Home telephone: ( ) | Work telephone: ( ) |
| Date of birth: Marital Status: SS#: | |
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Residence:
Number/Street City State Zip |
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| Billing address: | |
| Occupation: | Employed by: |
| Business address: | |
| Partner’s name: SS#: | |
| Partner’s employer: | Work telephone: ( ) |
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Business Adress:
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| Primary Insurance Company: | |
| Insurance mailing address: | |
| Policy holder name: | Telephone: ( ) |
| Policy ID#: Group #: Plan #: | |
| Relation to insured: Self Spouse Dependent Other | |
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OPTIONAL: (On a separate piece of paper) What is the general nature of the medical problem(s) for which you are seeking assistance? Please, give any known diagnoses, duration of symptoms, physicians seen and their addresses, if known, and treatments prescribed, including alternative forms of therapy that have been or will be used. What reading, research, and/or work have you done to solve this problem? PLEASE SEND ME ANY PERTINENT HOSPITAL RECORDS, LABORATORY, AND X-RAY REPORTS. |
| Emergency contact: | Address: | Telephone: |
| Referred by: |
| Assignment and Release: I hereby authorize my insurance benefits to be paid directly to my physician. I realize I am financially responsible for all non-covered invoices. I authorize my physician to release all information required in the processing of any claims. | |
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Signed: __________________________________________ |
Date: _________________ |