21081 S. Western Ave. Suite 150, Torrance, CA 90501

Western Medical Group

Demographics/Workers Compensation Injuries

  • WESTERN MEDICAL GROUP

  • ASSIGNMENT: I hereby assign my insurance benefits to be paid directly to the undersigned physician. I am financially responsible for non-covered services.
  • I hereby authorize the undersigned physician to release to my insurance carriers any information required to process this claim.
  • INFORMATION REQUIRED FOR CASE HISTORY FILE

  • Patient's Name / Nombre Del Paciente :
  • Home Address / Direccion Del Paciente :
  • Employer's Adrress / Direccion De Su Empleo:
  • Adrress / Direccion:
  • Employer's Address / Direccion De Empleo:
  • Insurance Company / Aseguranza de Compania: