JAMES D. WETHE, MD

PATIENT INFORMATION

Name			Age	Date of Birth		
Address		City	State	Zip Code		
Home Phone #	Cell Phone #	Work Phone #		E-mail Address*		

Employer Name and Address

Emergency Contact	Relationship	Phone #

Whom may we thank for referring you today?

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INSURANCE INFORMATION

Although Dr. Wethe accepts most insurance, he is not an in-network preferred provider for most plans. Your insurance company is your best resource for determining out of pocket expenses associated with seeing a non-preferred/out-of- network provider.

Primary Insurance:		Phone # 	 Address:					 Policy #	Group #		Effective Date 		 
Authorization for Release of Information
I hereby authorize James D. Wethe, M.D. to release information requested by my insurance company or Worker’s Compensation carrier. I also authorize James D. Wethe, M.D. to release information to any hospital or physician to whom I may be referred by this office.

Signature	Date

Relationship To Patient

Assignment of Benefits

I hereby authorize assignment and payment directly to James D. Wethe, M.D. of major medical benefits due me. 

I HEREBY AGREE TO PAY ANY AND ALL CHARGES THAT EXCEED OR THAT ARE NOT COVERED BY MY INSURANCE.

Signature	Date	Relationship