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Diagnosis Date: Dx___________ Dx___________ Dx___________ Dx___________

Procedure (CPT Codes) ________________________________________________


Patient Information

Patient's Name______________________________Date of Birth_______________

Address ____________________________________________________________

City ________________________ State _______________________ Zip ________

Day Phone__________________________Evening Phone ____________________

SSN ______________________________________________ Gender ___ M ___ F

Marital Status: ____ Single ____Married ____Divorced____Widowed ___Separated

Employer Name_______________________________________________________

Employer Address_____________________________________________________

Work Phone___________________________Home Phone ____________________

Student Status: ______Full ______Part time Name of school: _________________

Responsible Party Information

*If you are the responsible party mark “self” and move down to “insurance information”

Patient’s relationship to responsible party:_______self_______spouse ______child

Name_____________________________________Date of Birth_______________

Address ____________________________________________________________

City ________________________ State _______________________ Zip ________

Day Phone__________________________Evening Phone ____________________

SSN ______________________________________________ Gender ___ M ___ F

Marital Status: ____ Single ____Married ____Divorced____Widowed ___Separated

Employer Name_______________________________________________________

Employer Address_____________________________________________________

Work Phone___________________________Home Phone ____________________

Occupation __________________________________________________________

Insurance Information

(if you have more than two (2) insurance companies, please use the back of this form)

Insurance Co # 1: ____________________________________________________

Insurance Phone #: ___________________________________________________

Claims address: ______________________________________________________

City: ___________________________________State:________Zip:____________

Group or Policy #:_____________________________________________________

Effective Date: ________________________ Deductible: _____________________

Family Ded. $______________________ Ded. Remaining ____________________

Co-pay Amount: $_____________________________________________________

Insurance Co # 2: ____________________________________________________

Insurance Phone #: ___________________________________________________

Claims address: ______________________________________________________

City: ___________________________________State:________Zip:____________

Group or Policy #:_____________________________________________________

Effective Date: ________________________ Deductible: _____________________

Family Ded. $______________________ Ded. Remaining ____________________

Co-pay Amount: $_____________________________________________________

Assignment and Release

Patient's Signature: ___________________________________ Date___________

Print out (CTRL P TO PRINT) and mail or fax form to

Pain Managment Technologies, Inc.
1340 Home Avenue
Building A
Akron, OH 44310

FAX: 888-304-5454