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Rocky Mountain Allergy, Asthma, and Immunology, LLC

PLEASE FILL OUT EVERY SPACE. IF IT DOES NOT PERTAIN TO YOU, PLEASE WRITE N/A FOR NOT APPLICABLE

PATIENT INFORMATION

Last Name

First Name

Middle Initial

Gender

DOB

M F

Mailing Address

City

State

Zip

Home Phone #

Cell Phone #

Work Phone #

Social Sec. #

Employer Name & Address

Email Address

Spouse’s Name

Spouse’s DOB

Spouse’s Phone#

Marital Status

Ethnicity –

Race

Race/Ethnicity Questions are asked in order to identify additional care needs of our diverse patients. No Discrimination Intended

 Hispanic/Latino  Non-Hispanic/Latino

 Caucasian

 Hispanic

 African American

 Pacific Islander

 American Indian/Alaska Native

 Asian

How Did You Hear About Our Practice?

 Facebook

 Good 4 Utah

 Health Fair

 Insurance

 Internet Search

 KUTV

 Ogden Marathon

 Radio

 Seminar

 Twitter

 Another Patient (Name): ___________________________________________________  Other: ________________________________________________________

 Referring Provider: Provider Name ______________________________________ Provider Ph# ________________________ Facility _________________________

RESPONSIBLE PARTY INFORMATION

 Mother

 Father

 Self

Last Name (If Not Patient)

First Name

DOB

Gender

 Other _____________________

M F

Address

City

State

Zip

Primary Phone #

Social Sec. #

Employer

Business Phone #

PARENT / GUARDIAN INFORMATION

(FILL OUT IF PATIENT IS UNDER 18 YRS OF AGE)

Mother

Father

First & Last Name

Phone Number

Other: ______________________

Mother

Father

First & Last Name

Phone Number

Other: ______________________

INSURANCE INFORMATION

ID #

Group #

Primary Insurance

: Name & Address

Policy Holder Name

Policy Holder DOB

Social Security #

Effective Date

Policy Holder Address

Policy Holder Phone #

Relationship to Patient

Self Spouse Parent Other____

ID #

Group #

Secondary Insurance:

Name &Address

Policy Holder Name

Policy Holder DOB

Social Security #

Effective Date

Policy Holder Address

Policy Holder Phone #

Relationship to Patient

Self Spouse Parent Other____

EMERGENCY CONTACT

First & Last Name

Phone Number

Relationship to Patient

If this visit is due to an accident, please provide the information here.  Auto

 Industrial

Details:

Consent to Treat and to Disclose Protected Health Information:

I authorize the physician or physicians in charge of the care of the above named patient to

administer anesthetics and/or medications and to perform such operations and/or diagnostic procedures as may be deemed necessary by the physician for the diagnosis

and treatment of this patient.

The practice’s Written Privacy Notice provides detailed information on how we may use and disclose protected health information. By signing this consent form, you

acknowledge that you have received a copy of the Written Privacy Notice and are in agreement with our use and disclosure of protected health information for

treatment, payment, and health care operations. Patients injured at work typically obtain information through their adjuster or employer. I have read and understand the

above statements. Affixing my signature to this form represents my receipt of the Written Privacy notice, my consent to treatment, and the above listed uses of

protected health information.

______________________________________________________________

___________________

Signature of Patient / Responsible Party

Date