Patient Information Form

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Account No.______________________
Doctor’s No. _____________________ 
 
 
PLEASE ANSWER ALL QUESTIONS
 
NAME: LAST:____________________________________
FIRST    _________________________  MIDDLE  __________________
BIRTHDATE _________________  SS# _______________ 
   SEX           
RACE                                                                                                     ETHNIC ORIGIN 
HOME PHONE___________________________________ 
M   
 White/Caucasian      
Black/African American                         
Hispanic 
CELL PHONE ____________________________________ 
F     
Asian                          
Native Hawaiian or Pacific Islander        Non‐Hispanic 
 
EMAIL _________________________________________ 
                
Other Race                
American Indian/Alaskan
 
 
ADDRESS 2_________________________________________________ 
ADDRESS ______________________________________ 
STATE______________________________________________________ 
CITY __________________________________________ 
COUNTY____________________________________________________
ZIP CODE ___________________4 DIGIT_____________ 
COUNTRY______________________________________ 
MARITAL STATUS ____________________________________________ 
EMPLOYER _____________________________________ 
ADDRESS ___________________________________________________ 
WORK PHONE _________________EXT______________ 
PRIMARY CARE DOCTOR _______________________________________ 
RESPONSIBLE PARTY (Patients 18 years of age or younger)
NAME ______________________ BIRTHDATE _________
HOME PHONE ________________  CELL PHONE ___________________
ADDRESS ___________________  CITY ______________ 
STATE __________ ZIP__________  SS#___________________________ 
EMPLOYER___________________RELATIONSHIP______ 
MARITAL STATUS ______________  SEX__________________________ 
ADDRESS____________________ CITY ______________
STATE __________ ZIP __________ PHONE _______________________
 
 
 
MOTHER (Patients 18 years of age or younger)
NAME ______________________ BIRTHDATE _________
HOME PHONE ________________  CELL PHONE ___________________
ADDRESS ___________________  CITY ______________ 
STATE __________ ZIP__________  SS#___________________________ 
EMPLOYER_____________________________________ 
MARITAL STATUS ______________  SEX__________________________ 
ADDRESS____________________ CITY ______________ 
STATE __________ ZIP __________ PHONE _______________________ 
 
FATHER (Patients 18 years of age or younger)
NAME ______________________ BIRTHDATE _________
HOME PHONE ________________  CELL PHONE ___________________
ADDRESS ___________________  CITY ______________ 
STATE __________ ZIP__________  SS#___________________________ 
EMPLOYER_____________________________________ 
MARITAL STATUS ______________  SEX__________________________ 
ADDRESS____________________ CITY ______________ 
STATE __________ ZIP __________ PHONE _______________________ 
 
INSURANCE INFORMATION
1) INSURANCE CO________________________________
2) INSURANCE CO____________________________________________
ADDRESS ________________________ ______________ 
ADDRESS __________________________________________________ 
CITY __________________STATE______  ZIP__________ 
CITY ______________________ STATE_________  ZIP_______________ 
MEDICARE/ID#__________________________________ 
MEDICARE/ID#_______________________________________________ 
GROUP # ______________________________________ 
GROUP # ___________________________________________________ 
POLICY HOLDER INFO 
POLICY HOLDER INFO 
NAME_________________________________________ 
NAME______________________________________________________ 
RELATIONSHIP TO PATIENT  _______________________ 
RELATIONSHIP TO PATIENT ____________________________________ 
SS#___________________________________________ 
SS#________________________________________________________ 
DATE OF BIRTH _________________________________ 
DATE OF BIRTH ______________________________________________ 
EMPLOYER _____________________________________ 
EMPLOYER __________________________________________________
ADDRESS ______________________________________ 
ADDRESS ___________________________________________________ 
CITY _______________ ST __________ ZIP ___________ 
CITY ________________________ ST _______________ ZIP__________ 
 
(1) I understand that I am responsible for charges not covered or reimbursed by the above agents. I agree, in the event of non‐payment, to assume the cost of the 
interest, collection and legal action (if required). (2) I authorize my insurance carrier to release information regarding my coverage to Wilmington Health. I also authorize 
agents of any hospital, treatment center or previous physicians to furnish copies of any records of my medical history, services or treatments. I also authorize the release 
of any medical information and/or reports related to my treatment to any federal, state or accreditation agency, or any physician or insurance carrier as needed. I also 
agree to a review of my records for purposes of internal audits, research and quality assurance reviews within Wilmington Health. (3) My right to payment for all 
pharmaceuticals, procedures, tests, medical equipment rentals, supplies and nursing/physician services including major medical benefits are hereby assigned to 
Wilmington Health. This assignment covers any and all benefits under Medicare, other government sponsored programs, private insurance and any other health plans. I 
acknowledge this document as a legally binding assignment to collect my benefits as payment of claims for services. In the event my insurance carrier does not accept 
Assignment of Benefits, or if payments are made directly to me or my representative, I will insure such payment to Wilmington Health.  
Patient Signature _______________________________________________        Date/Time _________________________________________________ 
Responsible Party Signature ______________________________________         Date/Time _________________________________________________ 
 
 
 
 
 
 
   
         A copy of this authorization and assignment shall be considered as valid as the original. 

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