Patient Insurance Information

Please provide the following to begin the insurance claims fling process.
All information is personal and confdential.
PATIENT INFO!ATION
Patient Name: LIA SEBASTIAN NICOLAE MALE FEMALE
Date of Birth: 2 !"#!2""$ E!mai% A&&ress: S'NDNL()A*OO+COM
A&&ress: ,#$2 SE Ster%in- Ct.C%ac/amas.O0 12",$ for Mrs+ EMILIA 'OINEA
Cit3: State: 4i5:
*ome Phone: 6or/ Phone: Ce%% Phone:
PE"#I$IN% P&'"I#IAN
Ph3sician Name: DAN ST0E7A 8rou5 Practice Name: AMI!P0O'IDENCE
A&&ress: 29$ MEDICAL CENTE0 D0I'E
Cit3: 6EST *ILLS State: CA 4i5: 1,9"2
Phone: :,:!92!212, Fa;: :,:!2,1!#:2"
O<ce Contact Name: O<ce Contact Tit%e:
Date of Dia-nose&: 2"!"!2"," Chec/ One: T35e , T35e 2 8estationa%
PI!A' IN"(AN#E INFO!ATION
MASTE0CA0D IBAN: 0O9"B0DE,"S',",2##,""
B0ANC*: ","" B+0+D+!8+S+8+
*OLDE0: LIA SA'INA DANIELA State: 4i5:
A=TOS*IPMENT P0O80AM ! SEND 9 BO>ES
e;c%u&in- the ?o; @hich came @ith DE>COM
8rou5 Num?er:
Po%ic3 *o%&er Name: Date of Birth:
0e%ationshi5 to Patient: Se%f S5ouse Parent Other Em5%o3er:
"E#ON)A' IN"(AN#E INFO!ATION
Insurance Com5an3 Name: Phone:
C%aims Mai%in- A&&ress:
Cit3: State: 4i5:
Po%ic3 Num?er: 8rou5 Num?er:
Po%ic3 *o%&er Name: Date of Birth:
0e%ationshi5 to Patient: Se%f S5ouse Parent
Other
Em5%o3er:
6hi%e eAer3 attem5t is ma&e to 5roAi&e u5!to!&ate informationB De;ComB Inc+ &oes not ensure the accurac3 of the information
5roAi&e&+ Since hea%th or me&ica% insurance reim?ursement is aCecte& ?3 man3 factorsB De;ComB Inc+ ma/es no re5resentation or
-uarantee that a 5atient @i%% ?e successfu% in o?tainin- insurance reim?ursement or an3 other 5a3ment+
Please fa* completed form +with cop, of front - bac. of insurance card/ to0
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