Patient Name:(First) _____________ (M) ___ (Last)__________________ DOB:__/__/__

    Address: _______________________ City:__________________ State:___ Zip:_______

    Home Ph: (   )_________ SS#: ____-____-_____ Sex: M F  Marital Status: M-S-D-Sep-W 

Patient's Employer: ______________________  Work Phone#:(   )___________

    Address: _______________________ City:__________________ State:___ Zip:_______

    Occupation: _____________________________     Retired:  Yes  No

Spouse Name: _____________________________   DOB:__/__/__   SS#: ____-____-_____

    Spouse's Employer: _____________________  Work Phone#:(   )___________

    Employer's Address: __________________ City:____________ State:___ Zip:_______

    Occupation: _____________________________     Retired:  Yes  No

Family Physician: ___________________     City & State:___________________

Physician Ph#: ______________

List any allergies: __________________________________________________________

Referred to us by: ___________________________________________________________

Emergency contact (other than spouse):

Phone #: _____________     Relationship to you: ___________________

INSURANCE INFORMATION
Primary Coverage:                         Secondary Coverage:

Insurance Company:__________________      Insurance Company:__________________

Insurance Address:__________________      Insurance Address:__________________ 
 
ID#: __________ Group #: ___________      ID#: __________ Group #: ___________ 

Subscriber's Name:__________________      Subscriber's Name:__________________

Relat. to Subscriber: Self Spouse Child   Relat. to Subscriber: Self Spouse Child 

Is this: HMO PPO Group Other Copay $____  Is this: HMO PPO Group Other Copay $____ 

I hereby authorize the Corporation of Chesepeake and Washington Heart Care, PC to
apply for benefits on my behalf for services rendered by the office of Terence
Bertele, MD and his associates, and request that payments from Medicare, Maryland
Medical Assistance, BSBC NCA, BSBS MD and/or any other insurance carrier be made
directly to the office of Chesapeake and Washington Heart Care, PC. I certify
that the information I have reported with regard to my insurance coverage is
correct, and further authorize the release of any necessary information,
including medical information, for this or any related claim to the above named
billing agent(s), Medicare, BSBC NCA,BSBC MD, or any Insurance carrier. I permit
a copy of this authorization to be used in place of the original.

Date: _______________   Patient Signature: __________________________________