HEARTSHARE WELLNESS, LTD. Court St. Diagnostic & Treatment Center 50 Court Street, Suite, 901, Brooklyn, NY 11201 (718) 855-7707, ext. 8010, 8011 / Fax: (718) 855-7717

PATIENT INFORMATION Date: ___________________

Middle

Last Name: ____________________________ First Name: _________________________ Initial : ______

Address: _________________________________________________________________ Apt #: ________

City: ____________________________ State: ___________________ Zip Code: ____________

Telephone #: ______________________________________ Emergency #: ______________________________

Sex: Male [ ] Female [ ] Birth Date: ________________ S/S #: _____________________________

Natural Family [ ] Family Care [ ] IRA [ ] ICF [ ] Supported Apartment [ ]

Residence Name ________________________________ Residence Manager: ___________________________

Transportation Needed: [ ] Yes [ ] No [ ] Ambulatory [ ] Wheelchair [ ] High Top Wheelchair

Referred by: ________________________________________ Telephone Number _______________________

INSURANCE INFORMATION

Medicaid #: ______________________________ Seq #: _____ Medicare #: ____________________________

Other Insurance: Health Plan Name: __________________________________ Group #: ___________________

Primary Insured: _____________________________ Employer: _______________________________________

S/S#: _________________________________ Contact Number: ____________________________________

CORRESPONDENCE INFORMATION

Name of Parent/Guardian: ______________________________________________________________________

Address: __________________________ City______ State: _______ Zip Code _______ Tel #: ______________

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Emergency Contact: ______________________________ Relationship to Patient: _________________________

Home Number: __________________________________ Work Number: _______________________________

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Medicaid Service Coordinator: ___________________________________________________________________

Agency Name: _______________________________________________Tel #: ___________________________

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Primary Care Physician: ________________________________________Tel #: ___________________________

Office/Practice: _______________________________________________________________________________

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Attending Program (If Any): Day Treatment [ ] Day Hab [ ] Supported Employment [ ] Other [ ]

Name/Address: _______________________________________________________________________________

Contact Person: _______________________________________________ Tel #: _________________________

PLEASE READ AND SIGN BELOW

Authorization for Treatment

I hereby authorize HeartShare Wellness, Ltd. And the physicians in charge of the mentioned patient to carry out or provide such diagnostic evaluations and procedures, treatments, anesthetics/sedation, or protective devices as may be deemed necessary and advisable in his or her diagnosis or treatment.

Authorization for Release of Information

I hereby authorize HeartShare Wellness, Ltd. to release/request any/all information to clinicians and persons listed on this form relative to the mentioned patient for the purpose of facilitating continuity of care. I further authorize the release of any medical or other information when required by any insurance carrier.

Financial Agreement

I hereby authorize payment from any insurance carrier for services rendered to said patient by HeartShare Wellness, Ltd. be made directly to HeartShare Wellness, Ltd. in consideration of services rendered or to be rendered to the above patient by HeartShare Wellness, Ltd. I hereby guarantee payment of all bills rendered for said patient. I understand that all bills are payable and due upon receipt. I hereby accept the responsibility of notifying HeartShare Wellness, Ltd. Of any changes in medical coverage, address or phone number.

Signature: __________________________________________ Witness: ____________________________