Young Adult Confidentiality / Release Form Page 3
ADVERTISEMENT
1
2
3rd
column BELOW please place the following indicators of how you would like to be
In the 3
contacted about:
A = Appointment confirmation / reminder for an appointment already made
R = reminder that an physical is needed or a vaccine is due
B = Billing statements **note** only to mail address, text to cell, or email
G = general notices and medical issue
Self :
Cell Phone (voice)
Smoker: □ Yes
□ No
Text to cell phone
Email
Mother’s Information
Cell Phone (voice)
:
Name: __________________________
Text to cell phone
Birth date: _____________
Occupation: ____________________
Email
Smoker: □ Yes
□ No
Address if different than yours:
Work phone
Home land line:
Father’s Information
Cell Phone (voice)
:
Name: __________________________
Text to cell phone
Birth date: _____________
Occupation: ____________________
Email
Address if different than yours:
Work phone
Home Land line:
Insurance
Person Responsible for account ____________________________________
__________
Relation to patient__
Last Name
First Name
Middle
Primary Insurance Company ________________________________________ Phone __________________
Are patients covered by secondary insurance? ‚ yes ‚ no
Secondary Insurance
: If secondary insurance member is different from person responsible for account, please provide the following:
Person Responsible for account _____________________________________
__________
Relation to child ___
Last Name
First Name
Middle
Secondary Insurance Company ______________________________________Phone __________________
I authorize my insurance company to pay to the doctor or medical group all insurance benefits otherwise
payable to me for services rendered.
I authorize the use of this signature on all insurance submissions.
I authorize the doctor to release the minimum necessary information necessary to secure the payment of
benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.
Signature ______________________________________________
Date: ________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal