Continuing his Vision
Merrill P. Spencer, M.D. (1922-2006)		 icavllogo


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PATIENT INFORMATION


Date of Exam:  

Seen at Spencer Vascular before? Yes   No

Name:



(Last)

(First)

(Middle)
- -
Social Security Number
Birthdate:

Month Day Year  Age:


Sex:
M   F

Marital Status:
Single   Married   Divorced   Widowed   

Address:

Street

Apt / Suite #

City, State,ZIP
 
E-mail Address:

 

Patient Phone Numbers:
()
Home
()
Work
()
Alternate
Emergency Contact:
Phone Number: () 

Referring Physician:
Phone Number: () 
Primary Care Physician (PCP):
Phone Number: () 

Employer Information:
Employer name:
Employer Phone Number: () 


INSURANCE INFORMATION - PLEASE GIVE YOUR CARDS FOR COPYING

Primary Insurance:
Insured's Name:
Relationship to patient: Self   Spouse   Parent   Child  
Birthdate (MM/DD/YY):
ID Number:
Group Number:
 
Secondary Insurance:
Insured's Name:
Relationship to patient: Self   Spouse   Parent   Child  
Birthdate (MM/DD/YY):
ID Number:
Group Number:
 
IF YOU CURRENTLY LIVE IN A SKILLED NURSING FACILITY, PLEASE COMPLETE THIS SECTION:
Name of Skilled Nursing Facility:
Address:
Street City State ZIP Code

Consent for treatment, release of Insurance benefits and information: I, the undersigned, hereby authorize (a) my insurance benefits be paid directly to Spencer Vascular if applicable for any services rendered by Spencer Vascular (b) release of information including protected health information to insurance companies as needed to file for payment for services incurred (c) understand that I am financially responsible for any balance due to Spencer Vascular for charges related to services incurred by me (d) understand that some insurance companies may not cover the exam for the reason I was referred. Spencer Vascular will extend every effort to work with your insurance company but if that case should arise, I will be responsible for payment. (e) I understand that my test results may be used as aggregate data in support of clinical research trials.

SIGNATURE

DATE


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Our hours of operation for outpatient services are 8:30am to 5pm, Monday-Friday (except Holidays).
To schedule an exam, please call one of our locations below. To print out our referral form, please click on the link above.
Spencer Vascular accepts all patients and most insurance plans, including Medicare & Medicaid.

Swedish Hospital / Cherry Hill Campus
Jefferson Medical Tower
1600 E. Jefferson Street, Suite 500
Seattle, WA 98122
Tel: 206.320.4400
Fax: 206.320.4696 		Swedish Hospital / First Hill Campus
Nordstrom Medical Tower
1229 Madison Street, Suite 890
Seattle, WA 98104
Tel: 206.386.6980
Fax: 206.386.6606
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