Demographic Face Sheet Collins

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NEW  UPDATE 
DATE
PRIMARY CARE PROVIDER
PHARMACY NAME
REFERRED BY
PHARMACY PHONE
HIPAA AUTHORIZATION CODE
PATIENT INFORMATION
Acct Number
PATIENT SOCIAL SECURITY #
LAST
FIRST
MI.
BIRTHDATE
SEX
M  F 
ADDRESS
CITY
STATE
ZIP
MARITAL
STATUS
HOME PHONE
WORK PHONE
CELL PHONE
EMAIL ADDRESS
RACE  AMERINDIAN
 BLACK
 HISPANIC
 ASIAN
 WHITE
ETHNICITY  HISPANIC
 NON-HISPANIC
PREFERED LANGUAGE:
EMPLOYER/SCHOOL
OCCUPATION
EMPLOYER'S ADDRESS
CITY
STATE
ZIP
START DATE
NEXT OF KIN/EMERGENCY CONTACT
RELATIONSHIP
PHONE
(PERSON NOT LIVING WITH YOU)
PARENT/GUARANTOR INFORMATION- PERSON FINANCIALLY RESPONSIBLE FOR BILL
LAST
FIRST
MI.
BIRTHDATE
PARENT
(IF PATIENT A MINOR)
SPOUSE
OTHER ________________________
ADDRESS
CITY
STATE
ZIP
SOCIAL SECURITY #
(IF DIFFERENT FROM PT.)
HOME PHONE
WORK PHONE
CELL PHONE
EMAIL ADDRESS
EMPLOYER/SCHOOL
OCCUPATION
EMPLOYER'S ADDRESS
CITY
STATE
ZIP
START DATE
INSURANCE INFORMATION
Please complete all information to ensure accuracy in claim submission
INSURANCE COMPANY #1
POLICY/MEMBER ID #
GROUP #
COPAYS
SPEC - $
PRIM - $
POLICY HOLDER
ADDRESS
SSN
RELATION TO INSURED
(IF DIFFERENT)
SELF
SPOUSE
DOB
CITY
ST
ZIP
CHILD
OTHER
INSURANCE COMPANY #2
POLICY/MEMBER ID #
GROUP #
COPAYS
SPEC - $
PRIM - $
POLICY HOLDER
ADDRESS
SSN
RELATION TO INSURED
(IF DIFFERENT)
SELF
SPOUSE
DOB
CITY
ST
ZIP
CHILD
OTHER
INJURY INFORMATION
 WORK RELATED
 AUTO RELATED
/
/
IS INJURY
CLAIM #_________________
DATE OF INJURY
I, THE PATIENT OR GUARANTOR, CERTIFY THAT THE INFORMATION ON THIS FORM IS TRUE TO THE BEST OF MY KNOWLEDGE. I ACCEPT
RESPONSIBILITY FOR THE MEDICAL CHARGES INCURRED BY THE PATIENT AND AGREE TO PAY ALL BILLS AT THE TIME OF SERVICE UNLESS OTHER
ARRANGEMENTS ARE MADE. I AUTHORIZE PHYSICIAN AND PRACTICE TO RELEASE ANY INFORMATION TO PROCESS INSURANCE CLAIMS. I ALSO
AUTHORIZE MY INSURANCE CLAIMS TO BE PAID DIRECTLY TO THE PRACTICE OR ITS REPRESENTATIVE.
I UNDERSTAND THAT ALL SERVICES NOT
COVERED BY MY INSURANCE WILL BE MY RESPONSIBILITY.
PATIENT/GUARANTOR SIGNATURE
DATE
(PARENT IF PATIENT IS A MINOR)

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