Fillable Patient Information Form printable pdf download

LINCOLN CENTER

Chart Number:

OBSTETRICS & GYNECOLOGY

Lincoln Center Physician:

PATIENT INFORMATION (please notify our office of any changes in the following information)

Name:

Last

First

Middle

Suffix

Address:

(IF PO BOX, WE MUST ALSO HAVE HOUSE ADDRESS)

City / State / Zip:

Social Security Number

Date of Birth

Marital Status

Primary Care Physician

Home Phone

Work Phone, Extension

Cell Phone

Referring Physician

Email Address

Employer

Occupation

ETHNICITY:

RACE:

Preferred Language

____ Hispanic or Latino

____ American Indian or Alaska Native

____ Not Hispanic or Latino

____ Asian

Emergency Contact

____ Decline to Answer

____ Black or African American

Parent, Spouse, Nearest Friend or Relative

(

)

____ Hispanic or Latino

____ Native Hawaiian or Other Pacific Islander

____ White

How Related

____ Decline to Answer

Their Home Phone

Their Work Phone, Extension

Their Cell Phone

IF INSURANCE REQUIRES A REFERRAL, PLEASE HAVE IT WITH YOU OR HAVE IT MAILED TO US

Health Insurance Company (Primary)

Effective Date

Policy ID Number

Group Number

Name Policy is Under

Their Date of Birth

Their Employer

Their Sex

Health Insurance Company (Secondary)

Effective Date

Policy ID Number

Group Number

Name Policy is Under

Their Date of Birth

Their Employer

Their Sex

OFFICE CREDIT POLICIES:

Payment is requested when service is rendered. OB patients without insurance must have their estimated fee paid in full by delivery date. I hereby

assign benefits from Medicare/Medigap/Medicaid/my health insurance(s) to the Lincoln Center physicians, M. Morrison, Field-Kresie, Trobough, Gleason,

Dickson, Bonebrake, Teply and H. Morrison, for all services billed to Medicare/Medigap/Medicaid/my health insurance company(s) for which I have not

paid in full. A copy of this assignment shall be as valid as an original. I understand I will be financially responsible for any services considered to be

non-covered by Medicare/Medigap/Medicaid/my health insurance company(s). If my account is turned over to a collection agency, I understand that I

may be subject to interest charges. I authorize the release of any medical information necessary to process my claims, and for Utilization Review/Chart

Audits that may be required under the guidelines of Medicare/Medigap/Medicaid/my health insurance company(s). It is understood and agreed that the

physicians of Lincoln Center OB/GYN, PA have the right to designate which practitioner(s) will perform medical services requested by the undersigned

patient.

DATED:

SIGNED:

(01.2012)

Form K5