MRI Patient Demographic Form Signature: Type or Draw × Type Mode On. Draw Mode On. Type It Draw It Clear OPEN MRI of S.A.N.S.C. CONFIDENTIAL PATIENT INFORMATION SHEET DATE:PRIMARY/REFERRING DOCTOR:PHONE #:IS YOUR VISIT RELATED TO AN INJURY OR ACCIDENT? YES NO IF YES, WHAT KIND OF ACCIDENT OR INJURY? AUTO WORKER’S COMPENSATION PATIENT INFORMATION LAST NAME:FIRST NAME:MI:RESPONISIBLE PARTY (IF A MINOR):ADDRESS:APT #:CITY:STATE:ZIP:HOME PHONE #:WORK PHONE #:DATE OF BIRTH:SEX: M F SOCIAL SECURITY #: SINGLE MARRIED WIDOW SEPARATED DIVORCED OTHER EMPLOYER INFORMATION EMPLOYER NAME:OCCUPATION:EMPLOYER ADDRESS:CITY:STATE:ZIP: PRIMARY INSURANCE INSURANCE COMPANY:ADDRESS:PHONE #:POLICY HOLDER:DATE OF BIRTH:POLICY #:RELATIONSHIP TO INSURED: SELF SPOUSE CHILD OTHER SECONDARY INSURANCE INSURANCE COMPANY:ADDRESS:PHONE #:POLICY HOLDER:DATE OF BIRTH:POLICY #:RELATIONSHIP TO INSURED: SELF SPOUSE CHILD OTHER EMERGENCY CONTACT:RELATIONSHIP: Release of Information I hereby authorize South Atlanta Neurology and Spine Clinic to release any information concerning my treatment to any insurance company for the purpose of determining eligibility for payment of insurance benefits. This included information regarding treatment for substance abuse or HIV. I authorize South Atlanta Neurology and Spine Clinic to disclose protected health information (PHI) about me to the following person/people: Name:Relationship:Name:Relationship: This authorization will permit South Atlanta Neurology and Spine Clinic to release any and all information pertaining to my health and well-being.This authorization will expire on:. (There must be a date of expiration/event, whether it is 10-100 years, divorce, death, etc.) I understand that when my PHI is used or disclosed pursuant to this authorization, it may be subject to disclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to: South Atlanta Neurology and Spine Clinic, 518 Eagles Landing Parkway, Stockbridge, GA 30281. Signature of Patient or Legal GuardianDate