Health Insurance Application Form
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1The Family Health Center, P.C.
_____________
Account #
Patient Name:
________________________________
_____ Social Security Number: _______________________
_____/_____/_____
Date of Birth:
Sex:
Male,
Female Status:
Single
Married
Divorced
Widow
Mailing __________________________________________________________________________________
Drivers License #:____________________ State: _____________ Expiration date:_____________________
Home Phone: (_____)____________ Work Phone: (_____)_______________ Leave message?
Yes,
No
Message Phone: (_____)____________
Cell Phone: (_____)_______________
E-mail Address:
Leave message?
Yes,
No
I authorize this office to send any/all information/communications regarding my treatment to this E-mail
address. I accept and agree to this: Signature:______________________________________________
Responsible party information if patient is under age 18
Name:
DOB
____________________________________________
:____________________________________________
Mailing ________________________________
Physical ______________________________
Address ________________________________
Address ______________________________
/SSN#
Drivers License Number:
Responsible Party
Employer: ______________________________________
Occupation: ________________________
Address: _______________________________________
Phone: (_____)______________________
If patient is a child (under age 18) who may authorize treatment for them other than responsible party above?
Name:
Relationship:
Phone:
Emergency Contact: Nearest Friend or Relative Not Residing With You.
Name:
Relationship:
Phone:
Insurance Information
Do You Have Medical Insurance?
Yes,
),
no
(If yes, we need to copy your card
If No, you understand payment is expected at time of service unless other arrangements have been made.
Insurance: ___________________________
Secondary Insurance: ___________________________
Address: ____________________________
Address: ____________________________
____________________________
____________________________
Policy Number: ____________________________
Policy Number: ___________________________
Group Number: ____________________________
Group Number: ___________________________
Subscriber Name: ____________________________
Subscriber Name: ___________________________
Relationship: ____________________________
Relationship:___________________________
Subscriber DOB: ____________________________
Subscriber DOB: ___________________________
Workman’s Compensation?
Yes,
No,
Company Name:_________________________________
Auto Accident?
Yes,
No,
Address: _________________________________
Date of Accident:
Spouse Name: ___________________________________
SSN: _____________________________
Address: ___________________________________
DOB: _____________________________
Please List Other Immediate Family Members (May use back of sheet if necessary)
Name: _______________DOB _______
M,
F
Name: _______________DOB _______
M,
F
Name: _______________DOB _______
M,
F
Name: _______________DOB _______
M,
F
How did you hear about our office?
May we thank them for t heir referral?
Yes,
No
Ad,
Phone Book,
Friend or Relative
) _________________________
Other_____________________________
(specify
I authorize this office to release to the named insurance company any information necessary to expedite insurance
payment. I understand that I am responsible for all charges, regardless of insurance coverage.
I have been given/offered a copy of The Family Health Center, P.C.’s Notice of Privacy Practices.
:
Patient, Parent or Guardian Signature
____________________________________ Date: _____________
TFHC 03/10
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Parent category: Business