Medical History Questionnaire Form – Virtuous Wellness Center

Assignment of Benefits

Fields marked with an * are required

Patient Name *

ID # *

DOB *

Insurance Policy 1 Name/Number/Group # (if applicable) *

**IS PATIENT INSURED THROUGH SOMEONE ELSE’S POLICY? Give their info here: (otherwise, skip to Insurance Policy 2)

Policyholder Name

Date of Birth

SSN

Address (if different than Patient)

Relationship to Patient

Spouse
Parent
Other

If Other, please explain.

Employer

Ph#

Claim #

Employer Address

Insurance Policy 2 Name/Number/Group # (if applicable)

I hereby instruct and direct... *

...to pay by check made out to the “Healthcare Provider” to the right and mailed to the address on the right (not mine). If my/this current policy prohibits direct payment to doctor/therapist, I hereby also instruct and direct you to make out the check to me and mail it to the above address for the professional or medical expense benefits allowable, and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services rendered.

Assignment of Benefits

Virtuous Wellness Center273 Peninsula Farm RdArnold, MD 21012

Virtuous Wellness Center

273 Peninsula Farm Rd

Arnold, MD 21012