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Patient Information (Please Print)
Patient Name (last):_____________________________ (first) _______________________ (mi)____Spouse___________________
Street Address ______________________________________________________________________________________________________
City _____________________________________________ State _____________________________ Zip ____________________________
Home Phone _____________________________ Cell:_________________________________ Work: _____ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
D a t e o f B i r t h _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ S . S . N . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ S e x : % M a l e % F e m a l e
P r i m a r y C a r e P h y s i c i a n _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ R e f e r r i n g P h y s i c i a n : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
E m a i l address (for appt reminders and patient portal access): ______________________________________________________
Do not have email address: ( Do not wish to provide email address: (
Please list a local and mail order pharmacy if applicable.
Local Pharmacy Name:________________________________ Address or Crossroads: ____________________________
Mail Order Pharmacy:________________________________________________________
Marital Status: % S i n g l e % M a r r i e d % D i v o r c e d % W i d o w e d % S e p a r a t e d % P a r t n e r
R a c e : % A m e r i c a n I n d i a n o r A l a s k a N a t i v e % A s i a n % B l a c k o r A f r i c a n A m e r i c a n
% W h i t e % N a t i v e H a w a i i a n o r P a c i f i c I s l a n d e r % D e c l i n e d
E t h n i c i t y : % H i s p a n i c o r L a t i n o % N o t H i s p a n i c o r L a t i n o % D e c l i n e d
L a n g u a g e : % E n g l i s h % S p a n i s h % I n d i a n % R u s s i a n % O t h e r _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
I n C a s e o f a n E m e r g e n c y , P l e a s e N o t i f y : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
( O t h e r t h a n spouse)
Relationship ____________________________________ Phone ________________________________________________
Primary Insurance:
Insurance Company Name: _________________________________________________________________________
Policy/Member ID #: _______________________________________ Group #: _____________________________
Primary Policy Holder: % S e l f % S p o u s e % P a r e n t % O t h e r _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
P o l i c y H o l d e r s N a m e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
P o l i c y H o l d e r s D O B : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ S S N : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
S e c o n d a r y I n s u r a n c e :
I n s u r a n c e C o m p a n y N a m e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
P o l i c y / M e m b e r I D # : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ G r o u p # : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
P r i m a r y P o l i c y H o l d e r : % S e l f % S p o u s e % P a r e n t % O t h e r ____________________
Policy Holders Name: ____________________________________________________________________
Policy Holders DOB: ___________________________ SSN: ____________________________________
AUTHORIZATION
Patient and/or guarantor are responsible for charges incurred. It is a courtesy for our office to file your insurance; however you are responsible for your copay, deductible and/or percentage, which the insurance company is not liable for on the day of your visit. In the event your insurance company has not paid within 60 days you are responsible for the balance due. It is also the patients responsibility to obtain referrals from your primary care physicians when required. If the referral is not obtained before the visit, the patient is liable for payment in full on the date of service. If we are unable to obtain payment within a reasonable amount of time from the patient and/or guarantor we will place your account with a collection agency, which will leave you liable for additional expenses incurred if applicable. I have fully read and understand the above statement of payment policy. I hereby request any benefits on my behalf, to be paid to the physicians. I also authorize the release of any information acquired in the course of my treatment to my insurance company as needed to issue benefits. I authorize the physicians to administer such treatment, as they may deem advisable for my diagnosis and treatment. I certify that I have been made aware of the role and services offered by the physician, physician assistant and nurse practitioner and I consent to care by such providers. I understand that these services are voluntary and that I have the right to refuse these services. I also acknowledge that a copy of the practices privacy policy has been provided for my review.
___________________________________ _________________________
Signature Date
I authorize this facility to release information to (Please check all that apply and list complete names and phone #)
___ Spouse: _______________________________________________________________________
___ Children: _______________________________________________________________________
___ Others: ________________________________________________________________________
___ No one
_____________________________________ __________________________
Signature Date
Medicare Patients
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_____________________________________ __________________________
Signature Date
MEDICARE LIFETIME AUTHORIZATION
I certify that the information given by me in applying for payment under Title XVII of the Social Security Act is correct and authorize any holder of the medical information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I request that the payment of authorized benefits be made on my behalf. I assign the benefits payable for physician services to the physician or organization furnishing the services or authorized by such physician or organization to submit a claim to Medicare for payment. I request that this authorization also apply to all other insurances.
_____________________________________ __________________________
Signature Date
If signed by other than beneficiary, print name and state reason the patient was unable to sign:
______________________________________ ______________________________
Name Reason
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