Randy L. Morton, M.D.
3209 North Fourth Street, Suite 300
Longview, Texas 75605 (903) 753-7205

Print this Form
Patient Information
Name (first)___________________(middle)________________(last)_______________________
Address________________________________City____________St__________Zip__________
Home Phone_________________Work Phone_____________SS #________________________
DOB_____________Age_____Marital Status__________Spouse’s name____________________
Employer__________________________Occupation___________________________________
Employer Address__________________________City___________St______Zip_____________
Emergency Contact Name and Number: ______________________________________________
Which physician referred you to us?__________________________________________________

Responsible Party (if other than patient)
Name (first)____________________(middle)________________(last)______________________
Address________________________________City____________St__________Zip_________
Home Phone_________________Work Phone__________________SS #___________________
Employer__________________________Occupation___________________________________
Employer Address__________________________City___________St______Zip_____________

Insurance Information (if card not presented to staff)
Primary Insurance Company____________________________Phone_______________________
Address__________________________________City______________St_____Zip___________
Insured’s Name_________________DOB______ID#________________Group # ____________
Secondary Insurance Company__________________________Phone_______________________
Address__________________________________City______________St_____Zip___________
Insured’s Name_________________DOB______ID#_______________Group # _____________
Is this a result of a work injury?____Yes ____No   Date Injured:__________ Claim #____________
Is this a result of an auto accident? ___Yes ___No Date Injured:__________ Claim #____________

I authorize the release of any medical or other information necessary to process this claim. I also request
payment of government/medical benefits to the physician or party who provides services.
Patient’s or Responsible Party Signature: ________________________________Date__________