Patient Payment Form
ADVERTISEMENT
1
2Abington - Jefferson Health
Name: _________________________________________________________
________________
Gender: M F TG
(Last)
(First)
(Middle)
(Suffix or title)
Date of Birth: ______/ ______/______
S.S.N. ______-______-_______
Marital Status: S M D W Separated
Emergency Contact Person:
Street & Apt #: __________________________________________________
Name: __________________________
City:
_________________________State: _______ Zip: _______-_______
Relationship: _____________________
Phone: __________________________
Phone Numbers:
Preferred contact number?
Home: (
)_______-___________
Is this person your Care Giver? Y or N
Work: (
) _______- __________
Cell:
(
) _______- __________
Do you have an Advanced Directive? Y or N
E-mail: ___________________________________________
□
□
□
□
Race (check applicable):
Asian
Black or African American
American Indian or Alaska Native
White
□
□
□ Unknown/undetermined
Native Hawaiian or other Pacific Islander
Other
□
□
Ethnicity (check applicable):
Hispanic/Latino
Non-Hispanic/Non-Latino
□
□
□
□
□
Preferred language (check applicable):
English
Spanish
Portuguese
Korean
Other
The Responsible Party is the person who will be responsible for any unpaid balances after insurance payments.
Name: _________________________________________________________
_________________
(Last)
(First)
(Middle)
(Suffix or title)
Street: _________________________________________________________
Power of Attorney Information:
City:
_________________________State: _______ Zip: _______-_______
Name: __________________________
Preferred Phone Number :(
)_______-_____________
Addr: __________________________
Phone: __________________________
Date of Birth: ______/ ______/______
S.S.N. ______-______-_______
Relation to Patient: ______________________________________________
The Insurance Subscriber is the person who is the “holder” of the insurance policy covering the patient.
Name: _________________________________________________________
_________________
(Last)
(First)
(Middle)
(Suffix or title)
Street: _________________________________________________________
City:
_________________________State: _______ Zip: _______-_______
Preferred Phone Number :(
)_______-_____________
Date of Birth: ______/ ______/______
S.S.N. ______-______-_______
Relation to Patient: □ Self □ Spouse □ Parent □ Other
Employer: ___________________________
Subscriber Name / Relationship to Patient
Insurance Carrier
Policy Number
Group Number
Primary
Secondary
Preferred Pharmacy Name & Phone :_________________________________________________________________________
Prescription Plan Name, Phone and ID # : ____________________________________________________________________
____________________________________________________________________
(Please provide a copy of your prescription plan card if applicable)
Other Physicians you see: _________________________________________________________________________________
Updated 5/2016
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical