Sample New Patient Intake Form printable pdf download

NEW PATIENT INTAKE FORM

Date:__________________

Patient #___________

Doctor/Provider:_________________________

Name:_______________________________ Primary Phone: ____________________ (circle) Home Cell Work

Address:____________________________________City:___________________ State:______ Zip:___________

E-mail address:____________________________________ Alternate Phone: _____________________________

MAY WE: (circle all that apply)

CALL CELL

CALL HOME

CALL WORK

MAIL you about

APPOINTMENT REMINDERS

ACCOUNT UPDATES

CLINIC EVENTS BIRTHDAYS/ANNIVERSARIES

Age:_______ Birth Date:___________ Race:______ Marital: M S W D

Occupation:_________________________ Employer:________________________________________________

Employer's Address:__________________________________ Office

Phone:_____________________________

Spouse:___________________ Occupation:________________ Employer:_______________________________

How many children?____________Names and Ages of Children:________________________________________

___________________________________________________________________________________________

Name of Nearest Relative:________________________ Address:______________________Phone:___________

How were you referred to our office?______________________________________________________________

Please check any and all insurance coverage that may be applicable in this case:

Major Medical

Worker's Compensation

Medicaid

Medicare

Auto Accident

Medical Savings Account & Flex Plans

Other/Non-Insured/Cash

Name of Primary Insurance Company:___________________________________________________________

Name of Secondary Insurance Company (if any):___________________________________________________

AUTHORIZATION AND RELEASE: I authorize payment of insurance benefits directly to the provider or clinic. I authorize

my provider to release all information necessary to communicate with personal physicians and other healthcare providers

and payors and to secure the payment of benefits. I understand that I am responsible for all costs of medical care,

regardless of insurance coverage. I also understand that if I suspend or terminate my schedule of care as determined by

my treating doctor, any fees for professional services will be immediately due and payable.

The patient understands and agrees to allow this office to use their Patient Health Information for the purpose of

treatment, payment, healthcare operations, and coordination of care. We want you to know how your Patient

Health Information is going to be used in this office and your rights concerning those records. If you would like

to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health

Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing

this consent.

The following person(s) have my permission to receive my personal health information:

Patient's Signature:_____________________________________________________

Date:________________

Guardian's Signature Authorizing Care:_____________________________________

Date:________________

REVIEWED BY:

DATE:

PRINT NAME:

Sample New Patient Intake Form

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