Patient Information Form (Page 2 of 2) in pdf

2014

NE#_________

INSURANCE/POLICY HOLDER INFORMATION (CONTINUED)

Policy Holder Last Name: ________________________

Policy Holder First Name: ____________________________

Policy Holder Date of Birth:______________________

Name of Employer : _________________________________

Address: ______________________________________

Employer Address: __________________________________

Phone #: ______________________________________

City, State, Zip: _____________________________________

Name of Secondary Insurance: __________________________________________________________________

ID #: _________________________________________

Effective Date: ____________________ Copay: __________

Policy Holders Relationship to Patient: ❏SELF (skip to next section) ❏ Parent ❏ Spouse ❏ Employer ❏ Other

Policy Holder Last Name: ________________________

Policy Holder First Name: ____________________________

Policy Holder Date of Birth:______________________

Name of Employer : _________________________________

Address: ______________________________________

Employer Address: __________________________________

Phone #: ______________________________________

City, State, Zip: ____________________________________

IMPORTANT INFORMATION

PATIENT PORTAL

AT YOUR CONVENIENCE, 24/7

Northeast Medical Group (NEMG) is pleased to provide our patients with an easy-to-use, self-service Patient Portal that lets

you submit appointment requests and also offers you secure messaging to receive your lab results, visit summary notes and

other pertinent information from your doctor’s visit.

The NEMG Patient Portal lets you complete and receive medical information confidentially. Please ask our staff to send you an

invite to sign-up online for the Patient Portal at

PATIENT SATISFACTION SURVEY REGISTRATION

We are continuously trying to improve our service. It is important to us that we meet your needs and expectations, and you

leave our office satisfied.

YOUR FEEDBACK IS IMPORTANT TO US.

We will be asking you to provide us with your email address so that we may send you a link to complete a patient satisfaction

survey about your experience.

The survey should take approximately two (2) minutes to complete and will be conducted by our survey partner, Press Ganey.

Press Ganey will hold all your personal information and survey responses in strict confidence in compliance with HIPAA

patient privacy regulations. Press Ganey administers the survey to protect your identity from NEMG and will never share your

email address with third parties.

Rev. May 23, 2014

Patient Information Form Page 2