The Chiropractic Office of Dr. Kenneth Passero
228 West Rocks Rd, Norwalk, CT 06851
ph: (203) 750-0010 fax: (203) 750-0015
State_______________Zip Code________________Social Security #__________/_________/_________
Date of Birth_____________/_____________/______________Age_______________________________
Home Phone:(______)_____________________Work Phone:(______)____________________________
Cell Phone:(______)_______________________E-Mail Address:________________________________
Marital Status: S M D W # of children, ages and sex______________________________________
Name of Emergency Contact:_____________________________Phone #:_________________________
Referred to this office by:_________________________________________________________________
Please allow our office to make a copy of your insurance card
Is your current condition the result of an auto or work accident? Yes___ No ___ Auto ___ Work ___
Medical Release/Assignment of Benefits
I authorize the Chiropractic Office of Dr.Kenneth Passero to release any Protected Health Information necessary to process my claim for health care benefits. I agree to assign the benefits of my insurance carrier to Dr. Passero. I understand that I am fully responsible for any unpaid or unassigned portion of charges incurred at this office. Regardless of insurance status, charges for services rendered are ultimately the patient's responsibility.
Permission to communicate confidential health information
I authorize the Chiropractic Office of Dr. Kenneth Passero to communicate confidential health information to me via the following confidential formats: ___e-mail listed above, ___voicemail/answering machine at the following number:_________________________________: ____ Only speak with me directly!!