Patient Demographics Form - Southern California Heart Specialists printable pdf download

SOUTHERN CALIFORNIA HEART SPECIALISTS

PATIENT INFORMATION (Please fill out completely)

Last Name: ___________________________

First Name: ____________________

Middle Initial: ____

Date of Birth: __________________

Social Security Number: ____________________

Gender:

( )Female ( )Male

Marital Status:

( )Single ( )Married ( )Other

Home Street Address: ________________________________________

Apartment or Unit: _______

City: ________________________________________

State: _______________

Zip: __________

Home Phone: __________________

Work Phone: __________________

Mobile: ________________

Email Address: __________________________

Emergency Contact: ____________________________________

Emergency Phone Number: ______________________________

RESPONSIBLE PARTY INFORMATION (if different from the above)

Last Name: ___________________________

First Name: ____________________

Middle Initial: ____

Date of Birth: __________________

Social Security Number: ____________________

Gender:

( )Female ( )Male

Home Street Address: ________________________________________

Apartment or Unit: _______

City: ________________________________________

State: _______________

Zip: __________

Home Phone: __________________

Work Phone: __________________

Mobile: ________________

Relationship:

( )Patient is Self

( )Patient is Spouse

( )Patient is Child

( )Other

INSURANCE INFORMATION

Primary Insurance Company (1

Payer): _______________________________________________

Member ID: ____________________________

Group ID: ____________________

Insured Last Name: ______________________

First Name: ___________________

Middle Initial: ____

Date of Birth: ____________________

Gender:

( )Female

( )Male

Relationship:

( )Patient is Self

( )Patient is Spouse

( )Patient is Child

( )Other

Secondary Insurance Company (2

Payer): _____________________________________________

Member ID: ____________________________

Group ID: ____________________

Insured Last Name: ______________________

First Name: ___________________

Middle Initial: ____

Date of Birth: ____________________

Gender:

( )Female

( )Male

Relationship:

( )Patient is Self

( )Patient is Spouse

( )Patient is Child

( )Other

I hereby authorize payment directly to Southern California Heart Specialists (SCHS) in consideration of acceptance for services rendered and to be rendered

to me by any physician associate or professional staff member. I understand that I am financially responsible for the charges not covered by this authorization.

I further agree in the event of non-payment, to bear the cost of reasonable legal and attorney fees should this be required.

I hereby authorize SCHS to disclose when requested by the named insurance carrier or its representatives any and all information with respect to any

illness(es), medical history, or treatment and copies of all medical records. A photo-static copy of the authorization shall be considered as effective and valid as

the original.

THE UNDERSIGNED CERTIFIES THAT HE/SHE HAS READ THE FOREGOING, IS THE PATIENT, OR IS DULY AUTHORIZED BY OR ON BEHALF OF THE

PATIENT, TO EXECUTE THE ABOVE AND ACCEPT ITS TERMS, OR IS THE INSURED.

________________________________________________

________________

(SIGNATURE OF THE RESPONSIBLE PERSON)

(DATE)