Enrique Liñan, M.D.
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| 1317 Saint Claire Boulevard, Suite # A - 4 Mission,TX 78572 |
| (956) 581-6606 |
You may expedite your attention by printing and filling out this form.
Please bring your insurance cards, X-Ray / MRI reports and a list of Medications.
This Form may also be faxed to: (956) 581-6775.
PATIENT INFORMATION
Name:______________________________________________________________________
DOB:_______/______/_______ Phone: (________) _________ - _______________
Address: ___________________________________________________________________
City: ___________________________ State: ________ ZIP: ____________________
Primary Doctor _____________________________ Phone: (_____) _____ - __________
CONTACT PERSON
Name:_____________________________________________________________________
Relationship:_______________________ Phone: (_______) _______ - _____________
Address: __________________________________________________________________
City: ____________________________ State: ________ ZIP: __________________
INSURANCE INFORMATION
1.- Medicare Y N # _______________________________________________
2.- Medicaid Y N # _______________________________________________
3.- Other: __________________________________________________________
4. Other: __________________________________________________________
ASSIGNMENT OF INSURANCE BENEFITS / CONSENT FOR EVALUATION & TREATMENT
1. I authorize payment of Insurance Benefits directly to Dr. Enrique Linan
2. I consent to be evaluated and treated by Dr. Enrique Linan
3. I hereby authorize the release of any medical information necessary for my treatment.
Patient's signature:_________________________________ Date: _____/_____/______
Please bring your insurance cards, X-Ray / MRI reports and a list of Medications.
This Form may also be faxed to: (956) 581-6775.
PATIENT INFORMATION
Name:______________________________________________________________________
DOB:_______/______/_______ Phone: (________) _________ - _______________
Address: ___________________________________________________________________
City: ___________________________ State: ________ ZIP: ____________________
Primary Doctor _____________________________ Phone: (_____) _____ - __________
CONTACT PERSON
Name:_____________________________________________________________________
Relationship:_______________________ Phone: (_______) _______ - _____________
Address: __________________________________________________________________
City: ____________________________ State: ________ ZIP: __________________
INSURANCE INFORMATION
1.- Medicare Y N # _______________________________________________
2.- Medicaid Y N # _______________________________________________
3.- Other: __________________________________________________________
4. Other: __________________________________________________________
ASSIGNMENT OF INSURANCE BENEFITS / CONSENT FOR EVALUATION & TREATMENT
1. I authorize payment of Insurance Benefits directly to Dr. Enrique Linan
2. I consent to be evaluated and treated by Dr. Enrique Linan
3. I hereby authorize the release of any medical information necessary for my treatment.
Patient's signature:_________________________________ Date: _____/_____/______