Demographics Form
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1ASSOCIATED GYNECOLOGY: PATIENT DEMOGRAPHICS
REFERRING PHYSICIAN:_________________________________________________________________________
Name:_____________________________________________________DOB:___________________SS#:________________________
Marital Status:_____________ Home Phone:_____________________ Work#_______________________Cell #__________________
Address:__________________________________________________City__________________ State_________Zip________________
Employer____________________________________ Work Address_______________________________________________________
Spouse/Parent___________________________________ DOB:_______________SS#_____________________ Relation__________
Spouse Employer_______________________________Work Address:________________________________________________
INSURANCE CO____________________________________ Copy of Card Attached ______
Copay $___________(specialist)
Subscriber Name_______________________________________Relation to patient________________Subscriber DOB:__________
Secondary Insurance:_______________________________ Subscriber______________________________Relationship_________
Emergency contact:
___________________________________________Phone________________________________Relationship__________
Lab required by insurance _____________________
Radiology required by insurance________________________
CONTACT INFO: What is best way to get hold of you from 8-5:
Work
Cell
Home
OK to leave msg___________
RELEASE OF HEALTH INFORMATION:
We can only give information about you to you. If you would like to give us permission to discuss protected information with other family
members, please fill out name and circle yes or no for each and initial.
Spouse/other ____________________________________Medical Issues Yes NO
Insur/billing
Yes NO __________(initial)
HIPPA:
Please initial that you have received or been offered a copy of our HIPPA policy for protected health information
_________(initial)
Do you have an ADVANCED DIRECTIVE: ____yes
___no
TYPE: ___Living Will or ____Durable Power of Attorney for Health Care
Please provide copy of your Advance Directive to our office for your file.
Would you like information on Advance Directives?
____yes
_____no
I, the undersigned, certify that I or my dependent have insurance coverage with the above named insurance company, and assign directly to
ASSOCIATED GYNECOLOGY, all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am
financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary
to secure the payment of benefits. I authorize use of this signature on all insurance submission forms.
____________________________________________
_________________________________
________________________
Signature of responsible party
Relationship to patient
Date
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Parent category: Medical