General Patient information

Please Complete The Form Below - All * Fields are Required

Patient Name:*

Street Address:*

Address Line 2:

City:*

State:*

Postal Code/Zip:*

Home Phone:*

Work Phone:*

Cell Phone:

Fax number:

Date of Birth*

Sex:*

Please choose your gender Male Female

Social Security Number:

Marital Status:*

Please choose your marital status Single Married Divorced Seperated Widowed Other

Legal Guardian'sInformation (If Under 18)

Guardian's Name:

Work Phone:

Extended Information - All * Fields are Required

Email Address:*

Emergency Conact's Name:*

Contact Phone:*

Relationship:*

Is this a work related claim?*

Please choose Yes or No Yes No

Is this an accident related claim?*

Please choose Yes or No Yes No

Primary Insurance Information (Primary Holder) - All * Fields are Required

Relationship to Patient:*

Please Choose One Self Spouse Child Other Self Pay

If Self, Please Skip the Rest of the Information

Primary Holder's Name:

Date of Birth:

Sex:

Please choose the gender Male Female

Phone Number:

Social Security Number:

Secondary Insurance Information (Primary Holder)

Relationship to Patient:*

Please Choose One Self Spouse Child Other None

If Self, Please Skip the Rest of the Information

Primary Holder's Name:

Date of Birth:

Sex:

Please choose the gender Male Female

Phone Number:

Social Security Number:

Appointment Date/Patient Comments

Date of Appointment*

Primary Care Physician*

Please choose your Physician Martha Kendall, MD Milly Shah, MD Sunanda Sindhwani, MD Fred Taweel, MD John Valenti, MD

Questions / Comment(s):

IMAR Agreement Policy

I hereby authorize Internal Medicine Associates of Reston, LLP to apply for benefits for covered services rendered by the physician. I request payment from the above named insurance company, Medicare B or other insurance carrier to be made directly to the above named group. I certify that the information I have reported with regard to my insurance iscorrect and further authorize the release of any necessary information,including medical information to the above named insurance carrier, or named group, or to my referring physician (in case of Medicare, HCFA.) This authorization may be revoked by my insurance carrier or me at any time in writing. I understand and agree to be responsible for any portion of this claim that for any reason is not covered by my insurance. I further understand that any legal fees incurred to collect this claim are my responsibility as well as any service charges assesed to accounts with returned checks or invalid credit card purchases.

Please mark this box if you, the patient/responsible party understand and agree to the above policy.*

Please Verify the Information You Entered then Click Submit.