New Patient Packet - North Texas Perinatal Associates printable pdf download

New Patient Packet - North Texas Perinatal Associates

North Texas Perinatal Associates

“Committed to turning high-risk pregnancies into low-risk deliveries.”

PATIENT INFORMATION FORM

Please print all information in the space provided. Sign and date at the bottom of each form.

PATIENT INFORMATION

Referring Doctor-Midwife

Date:

Last Name:

First Name:

M.I.:

Home Address:

Apt:

City:

State:

ZIP Code:

Home Phone:

Work Phone:

Cell Phone:

Email Address:

Appt. Reminders: qPhone qText qEmail

SSN:

DOB:

Age:

Employe:

Employer Address:

DL Number:

DL State:

Spouse’ s -Partner’ s Name:

SSN:

DOB:

Spouse’ s -Partner’ s Employer:

Spouse’ s -Partner’ s Employer Address:

Primary Insurance

Insurance Company:

Phone Number:

Billing Address:

Name of Insured:

Relationship:

Insured’s ID Number:

Group Number:

If patient is under parent’s insurance, please complete the following

Name of Insured:

DOB:

Relationship:

Employer:

Phone Number:

Emergency Contact Information (Please list someone not living in the same house hold.)

First Name:

Last Name:

Relationship:

Home Phone:

Work Phone:

Cell Phone:

I hereby authorize payment of medical benefits billed to my insurance to North Texas Perinatal Associates. I hereby accept responsibility for payment for any service(s)

provided to me that is not covered by my insurance. I also accept responsibility for fees that exceed the payment made by my insurance, if the Practice does not par-

ticipate with my insurance. I agree to pay all copayments, coinsurance, and deductibles at the time the service is rendered.

________________________________

__________________________________

Date of Signature

Signature of Patient or Guardian