Patient Information (Confidential) Form

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Patient Information (Confidential)
MRN #
Name
Home Phone
(First)
(Middle)
(Last)
(Goes By/Nickname)
Address
Apt/Lot #
City
State
Zip
Cell Phone
Date of Birth
Age
SS #
Sex:
Male
Female
Language : □ English
□ Spanish
□ Chinese
□ French
□ German
□ Japanese
□ Korean
□ Vietnamese
□ Other __________________
□ American Indian or Alaska Native
□ Asian
□ Black or African American
□ Hispanic
Race:
□ Native Hawaiian or Other Pacific Islander
□ White
□ Multi-Racial or Other
□ Declined
□ Hispanic or Latino
□ Non-Hispanic or Non-Latino
□ Declined
Ethnicity:
Collecting race, ethnicity, and language data using standard categories helps us make sure that everyone is receiving the same high-quality care.
□ Print
□ Patient Portal
□ Declined
Preferred method of communication for receiving a Clinical Summary:
□ Home PH
□ Cell PH
□ Mail
□ Patient Portal
□ Text Message
Preferred method of communication for receiving appointment reminder:
Preferred method of communication for receiving health management reminders: □ Home PH
□ Cell PH
□ Mail
□ Patient Portal
□ Text Message
Primary Care Physician
Referring Physician
Emergency Contact(s): Name
Relationship
Phone
Name
Relationship
Phone
Person Financially Responsible (Guarantor)
Relationship
Person Responsible for Account
to Patient
Address
Home Phone
City
State
Zip
Cell Phone
Date of Birth
SS #
Sex:
Male
Female
Employer
Work Phone
Power of Attorney
If Patient is Under 18 years old:
Mother’s Full Name
Employer ________________________________________ Work Phone _____________________
Mother’s Maiden Name ___________________________________
Address
Home Phone
City
State
Zip
Cell Phone
Date of Birth
SS #
Email Address__________________________________________
Father’s Full Name
Employer ________________________________________ Work Phone _____________________
Address
Home Phone
City
State
Zip
Cell Phone
Date of Birth
SS #
Email Address__________________________________________
Child Resides with: ____________________________________________________________
Other children in the family treated in our office:
Child’s Full Name: _____________________________________________________________
(1)
DOB: ____________________
(2) Child’s Full Name: _____________________________________________________________
DOB: ____________________
(3) Child’s Full Name: _____________________________________________________________
DOB: ____________________
(4) Child’s Full Name: _____________________________________________________________
DOB: ____________________
*****Insurance Information*****
Please provide card for receptionist to copy
Authorization for the release of medical information and assignment of benefits
I authorize the release of my medical records from Cornerstone Healthcare, P.A. in order to process any claims. I authorize you to release copies of my medical records including current and
previous records from other medical facilities to other offices which are a part of Cornerstone Healthcare, P.A. I hereby authorize payment directly to this medical association for the medical care
and/or surgical benefits that is entitled to under my insurance plans. I understand that as the patient (or the patient’s parent/guardian) I am responsible for any unpaid balance on this account. I
also understand that if any charges are not covered by insurance, workers’ compensation or other third party payers, I am responsible for full payment. I understand that fees for visits,
examinations or treatments are payable at the time of service unless covered by insurance or arrangements have been made in advance. Fees for special medical reports are payable in advance.
Charges for accidental injury are payable at the time of service, regardless of any pending litigation or settlement. All telephone numbers provided by you may be subject to receiving calls
from an automated dialer using a pre-recorded, artificial voice message or live operator call. You give your prior express consent to receive such phone calls, including any
calls made to your provided cellular telephone number.
Signature:
Date:
Patient/Parent/Person Financially Responsible
_____Acct Updtd
_____Pat Updtd
_____Ins Updtd
_____Comments Updtd
_____Scanned
Rev 02/15

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