ACCIDENTAL INJURY

Is visit result of an accident? (Examples: auto accident, workers compensation, etc.)

Yes

No

Date

GUARANTOR INFORMATION

(This is the person responsible for the balance after insurance pays on the account.)

Parent/guardian presenting minor child for treatment will be listed as the guarantor. This person will be responsible for any balances due after insurance has paid. If 18 or older, you are your own guarantor and do not have to complete this section unless there is a legal designation for your care, such as a power of attorney.

*****IF SELF DO NOT COMPLETE THIS SECTION*****

Guarantor Name
last, first, middle

Guarantor SS#

Relationship

Primary Phone

Address

Alternate Phone

City, State, Zip Code

P.O. Box (Required if Applicable)

City, State, Zip Code

Guarantor Employer

Work Phone

PRIMARY INSURANCE INFORMATION

Insurance Co. Name:

ID#
Single, Married, Divorced, Widowed, Partnered ,

Effective Date

Patient Employment Status
(full-time, part-time, unemployed, retired, military, retired military, full or part-time student)

SUBSCRIBER INFORMATION

(This is the person insured by the company listed above.)

*****IF SELF DO NOT COMPLETE THIS SECTION*****

Patient Relationship to Subscriber:

Full Name

Sex
Male/Female

Date of Birth

Address

SS#

City, State, Zip Code

Phone

Employer Name

Work Phone

AUTHORIZATION

I authorize medical evaluation & treatment, and release of information for insurance/medical purpose concerning my illness and treatment. I hereby, authorize payment from my insurance company to SERENE CARE CLINICS SERENE CARE HOLDINGS AND AFFILIATES for services rendered. I will be responsible for any amount not covered by my insurance.

Do You Authorize

Yes

Electronic Signature (Type Name)

Date Signed

Next: Medication, Allergies & Immunizations

Location

10806 Reisterstown Rd, Ste 1F
Owings Mills, MD 21117

Make an Appointment

We operate by Appointments Only

Book Now

Open Hours

Tuesday – Friday: 8:30am – 6pm
Monday & Saturday: 10am – 4pm

Call Us

410-204-2866