Scotland Medical Center P.A.
M. Navaid MD
J. Iqbal MD
422 King Street, Laurinburg, NC 28352
Patient Information Form
Name: ____________________________________ Phone #: ___________________________
Address: _______________________City: _______________ State: ________ Zip: __________
Birthday: ____________________ Sex: M F Race: ___________ Marital Status: ____________
Employer: ___________________ Work #: _________________
Please check all that apply to you:
I have: *Medicaid ______ **Medicare ______ ***Insurance _______ Self-Pay _______
*If you have NC Medicaid, you are required to pay a $3.00 co-payment each time you visit the doctor. This payment
is required when services are rendered
**If you have Medicare, you are required to meet a $100.00 deductible each year. Please let us know if you have
met your deductible for this year.
***Your insurance many also require a co-payment for each doctor visit. Please refer to your insurance card for the
co-payment amount; this payment is due when services are rendered.
Emergency Contact: ______________________________ Phone #: _______________________
Referring Physician: ______________________________ Phone #: ______________________
Who is financially responsible for your bill? __________________________________________
Primary insurance company: ______________________________________________________
Secondary Insurance Company: ___________________________________________________
I will be paying by: Cash______ Check________
I understand and agree that I am ultimately responsible for the balance of my accounts for any
professional services rendered. I have read all the information and have completed the above
myself. I notify you of any changes in my status of the above information.
Signature: _____________________________________ Date: __________________________
I, _______________________, give Scotland Medical Center P.A. permission to release my
Medical Information to the following people. This may be done in person or by the phone.
Name Address Phone # Relationship
Patient’s Signature: _________________________________
Date: _____________________________________________
Witness: ___________________________________________
