Sherry Nussbaum, M.D., P.A.
1008 North Bowen Road
Arlington, TX 76012
(817) 861-2288
www.sherrynussbaummd.com

Patient Registration

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Patient Information

Insurance Information

 

We apologize but we are unable to accept Cook Childrens STAR program or any program with state Medicaid including: Traditional MDCD, TMHP, or other Medicaid subprograms of AETNA, UHC and other private insurance companies. *

Parent/Guardian #1 Information

Guarantor Relationship to Patient: *
 

Parent/Guardian #2

If you wish to add a second parent/guardian, please fill out the following information. 
Otherwise, skip down to Emergency Contact Information.
Guarantor Relationship to Patient:
 

Emergency Contact

If you wish to add an Emergency Contact, please fill out the following information. 
Otherwise, proceed to the next page. 

Documents




Authorization

AUTHORIZATION TO PAY BENEFITS TO PHYSICIAN: I hereby authorize payment directly to the physician of the surgical and/or medical benefits, if any, otherwise payable to me for his/her services as described, realizing I am responsible to pay non-covered services.

AUTHORIZATION TO RELEASE INFORMATION:  I hereby authorize the physician to release any information acquired in the course of my treatment necessary to process insurance claims.
 *
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