Patient Demographic Information Form printable pdf download

INTERNAL MEDICINE at the CROSSINGS

PATIENT DEMOGRAPHIC INFORMATION (PLEASE PRINT)

Last Name: _____________________________ First Name: _____________________________ MI: _______

SS #: ____________________________ DOB: _____________________ Male: _________ Female: ________

Address___________________________________________________________________________________

City: _________________________________________ State: __________________ Zip Code: ___________

Home Phone: __________________________________ Cell Phone: __________________________________

Employer: ____________________________________________ Phone: ______________________________

Preferred Daytime Contact Number: ____________________________________________________________

Optional Information: Marital Status: _____________________ Primary Language: ____________________

Race:

American Indian

African American

Asian

Native Hawaiian

White

Other

Ethnicity:

Hispanic / Latino

NOT Hispanic / Latino

May we leave messages on your answering machine?

Test Results: YES___________ NO___________ Appointments: YES___________ NO___________

PRIMARY INSURANCE

SECONDARY INSURANCE

Insurance Name: ____________________________

Insured Name: ______________________________

Insured SS#: ________________________________

For your privacy, who may receive information regarding your Protected Health Information?

(In order to speak with anyone regarding appointments or your care this must be completed)

Name: __________________________________ Phone #: ____________________ Relation: _____________

I have received a copy of the Privacy Rules from this provider and authorized the above list of persons

who may receive my Protected Health Information.

PLEASE READ CAREFULLY: I acknowledge that I am responsible for all charges incurred. I understand

that Joseph P. Griffin, Jr. MD PC may submit charges to the appropriate insurance company, however, this does

not relieve me of the responsibility to cover any charges my insurance fails to pay. Also, by signing this form, I

hereby authorize the release of medical information needed by insurance companies to process a claim, as well

as medical records that may benefit any physician who may be involved in my care.

SIGNATURE____________________________________________________ DATE: ___________________

Patient Demographic Information Form