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Mission Statement

At Outpatient Surgical Center of Ponca City, we strive to make the patient’s experience positive – from scheduling the surgery through postoperative follow up.
Our goal is to provide friendly, professional care in a clean, relaxed atmosphere, at an affordable cost. We care about our patients and their families.

OUTPATIENT SURGICAL CENTER OF PONCA CITY
400 Fairview, Suite 50 Ponca City, OK 74601 (580) 762-0695
PATIENT INFORMATION:
(PLEASE COMPLETE FORM AS COMPLETELY AS POSSIBLE)

Dont want to fill it out online - click here for printable form

Email Address:

Patient's Name:

Sex:

Home Phone:

Cell Phone or Other Phone

Maiden Name:

Place of Birth:

Home/Physical

Address:

County:

City: State:

Zip Code:

Age: Date of Birth

Social Security Number:

Occupation (If retired, list job prior to retirement):

Employers Address:

Employers Phone:

Spouse:

Are/Were you in the Military?

Data Requested by State of Oklahoma: Please check appropriate

Race: American Indian/Eskimo Asian/Islander Black White

Other

Ethnicity: Hispanic Origin Not of Hispanic Origin Unknown

Maritial Status: Single Married Life Partner Legally Separated

Divorced Widowed

Insurance Information:

Insurance:

Insurance ID:

Group:

Name of Subscriber

Subscriber SSN

Medical History:

Family History of Cancer?

Relationship

Do you smoke? Do you drink alcohol?

How much?

IS CONDITION RELATED TO ANY OF THE FOLLOWING?

Employment? Auto Accident? Other Accident?

Date of Injury

Have you had treatment at this facility before?

PERSON RESPONSIBLE FOR PAYMENT (IF OTHER THAN PATIENT):

Name: Sex:

Home Phone:

Cell Phone or Other Phone

Home Address:

City: State: Zip Code

Social Security Number:

Date of Birth:

Relationship to Patient:

Employer:

Employers Address:

Employers Phone:

AUTHORIZATION TO RELEASE INFORMATION AND ASSIGNMENT OF BENEFITS

I hereby assign payment directly to the Outpatient Surgical Center of Ponca City all surgical and/or medical benefits. I understand that charges for surgical procedure(s) not paid by my insurance plan(s) are MY responsibility. All accounts that are delinquent over 30 days will enter the Center’s collection process. Collection actions include Collection Agencies, Small Claims and Civil Court, and garnishment. If OPSC has to refer my account to a collection agency or small claims court, I agree to pay all of the collection cost and/or court costs that are incurred. If OPSC has to refer collection of the balance to a lawyer, I agree to pay all lawyer’s fees which they incur plus all court costs. And I have had the opportunity to review the Payment Policy of the Outpatient Surgical Center of Ponca City. I also authorize the Outpatient Surgical Center of Ponca City to release any medical information necessary to process this claim.

X _______________________________________________________

Sign and Date

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