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Patient Information-Family Medical Center Form

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FAMILY MEDICAL CENTER

•

Joel G. Wright M.D.

Clinton D. Damron D.O.

Matthew R. Sampson M.D.

Trina S. Gomm FNP-BC

1492 S. 20

Avenue, Safford, AZ 85546 • Phone: (928) 348-2151 • Fax: (928) 428-3617

PATIENT INFORMATION:

Patient’s Name ____________________________ Marital Status _______________SS# ________________

Mailing Address ___________________________City/State ________________________Zip ____________

Birth date _______________________Age ______Male/Female ___________ Phone # _________________

Employer_____________________________Occupation_______________________Work # ______________

Do you have an Advanced Directive (Living Will):

Yes

No Pharmacy __________________________

IF PATIENT IS A MINOR OR STUDENT:

Mother’s Name ___________________________ Birth date ______________ SS# ___________________

Address ______________________________________________________ Phone# _____________________

Father’s Name ____________________________ Birth date ______________ SS# ___________________

Address ______________________________________________________ Phone# _____________________

INSURANCE INFORMATION:

Primary Ins Company ______________________________ ID#_______________ Group # _______________

Policy Holder’s Name_________________________ Employer_____________________ DOB ____________

Secondary Ins Company _________________________ ID#____________________ Group # _____________

Policy Holder’s Name___________________________ Employer_____________________ DOB __________

EMERGENCY CONTACT (Person out of the Home)

Name __________________________________ Phone#___________________ Relationship _____________

CONSENT AND AUTHORIZATION:

I hereby give my consent and authorization for Family Medical Center to use or disclose my personal health

information as they see fit. I understand I have the right to review the provider’s privacy notice, to request

restrictions and to revoke this consent at any time. This consent and authorization is valid for Family Medical

Center. I also authorize and request that payment under my insurance programs be made directly to the above

provider for any services furnished to me. I understand even though I have insurance, I am responsible for

payment.

Signed

Date

Patient Information-Family Medical Center Form

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