510 E. Loop 281 ~ Longview, TX 75605-5076

903.758.9904 ~ 800.525.2420 ~ Fax 903.236.9786

WHB ACCOUNT #______________________

Last Name First Name MI			Cell Phone	Date of Birth		Sex F M
Address City State Zip Code					Home Phone
Marital Status Single Married Widowed Divorced	Email Address
Employment Information – You (if needed for Insurance)		Employment Information – Your Spouse (if needed for Insurance)
Company Name		Company Name
Address		Address
Job Title / Position		Job Title / Position
Work Phone		Work Phone
Emergency Contact Relationship Address Phone

How did you find our Internet Site?

Physician’s Name

Diagnosis

Date of Surgery

Do You Have a Prescription?

Yes No

Physician’s Address and Phone Number

Women’s Health Boutique is willing to accept assignment on certain products and services from qualified insurance carriers and Medicare. If you would like us to file your claim for you, please fill out the following information so we may review it to make a determination of eligibility for assignment. We must file your claim to Medicare, even if you choose to pay for the products. As a courtesy, we will file your claim to other insurance, unassigned, after you pay for the products.

Primary Insurance	Other Insurance
Insured’s Name Relationship Date of Birth	Insured’s Name Relationship Date of Birth
Insurance Company’s Name	Insurance Company’s Name Spouse’s Soc. Sec. No.
Group Name Group No. ID/Member No.	Group Name Group No. ID/Member No.
Claims Address	Claims Address
City State Zip Code	City State Zip Code
Phone	Phone
Primary Care Physician Phone	Primary Care Physician Phone

I request that payment of authorized Medical/Insurance benefits be made on my behalf to Women’s Health Boutique for any services furnished to me by this provider.

I authorize any holder of medical information concerning me to be released to Women’s Health Boutique or to the Health Care Administration (HCFA) and its agents, any information needed to determine these benefits or the benefits payable for related services. Women’s Health Boutique assumes unconditional responsibility for refunding any overpayment that occurs because the Medicare/Insurance carrier did not receive prompt notice that the equipment was returned. I agree to pay any amount owed to Women’s Health Boutique not reimbursed by Medicare/Insurance including any service or product not covered by Medicare/Insurance, the co-payment amount, any unsatisfied deductible, or any combination of these.

Signature ___________________________________________________________________________________________ Date ___________________________