Patient Information Sheet

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PATIENT INFORMATION SHEET
Patient Name: _______________________________________________________Jr. / Sr. / III
Marital Status: S M D W O
(Last)
(First)
(MI)
Address (Mailing): __________________________________________________ City: _____________________________
State: ______ Zip: ________________ Physical Address (If Different): ________________________________________
Sex: M or F
Date of Birth: ___________ Social Security #: __________________ Email: ______________________
Home Phone: _______________________ Cell Phone: _______________________ Work Phone: _____________________
Employer: _____________________________ Address: ______________________________________________________
City: ________________________ State: _________ Zip: _____________ Occupation: ___________________________
Whom may we contact in case of emergency: _____________________________ Relationship: _______________________
Phone: __________________________
Are there other members of the immediate family who have already been to this office? Y or N
If so, list their names: ___________________________________________________________________________________
INSURANCE INFORMATION
Primary Insurance
Patient’s Insurance ID#: ______________________________________________
Subscriber (whose job provides plan?): ____________________________________________________________________
(Last)
(First)
(MI)
Subscriber’s Date of Birth: _________________Sex: M or F Subscriber’s Social Security #: ______________________
Insurance Company: ________________________________ ID #: ____________________ Group#: _________________
Second Insurance? Y or N
Patient’s Insurance ID#: _____________________________________________
Subscriber: ____________________________________________________________________________________________
(Last)
(First)
(MI)
Subscriber’s Date of Birth: _________________ Sex: M or F Subscriber’s Social Security #: ______________________
Insurance Company: _________________________________ ID #: ____________________ Group #: ________________
If there is a third plan, please put information on back. Is this related to a Motor Vehicle Accident or
Worker’s Comp ?
Ultimately, who is responsible for the bill (the Guarantor)?: _____________________________________________________
Address: ______________________________________________________________________________________________
AUTHORIZATION TO PAY INSURANCE BENEFITS/CONSENT FOR TREATMENT
If required, I hereby authorize payment directly to the physician responsible for my care. I understand that I am financially
responsible to my physician for all fees incurred and for fees not covered by this authorization. I authorize the release of my
medical information to my third party payor in order to obtain payment. I hereby authorize the physician to release any
medical information required for my examination or treatment. I understand that payment is expected at rendering of services
unless other arrangements have been made. I hereby also consent to medical treatment for my present condition or injury, and
for any illness or injury incurred at any time after the date noted below. I have completed this form fully and completely, and
certify that I am the patient or duly authorized general agent of the patient, authorized to furnish the information requested. I
understand that even if I have some type of insurance coverage, I am responsible for payment of services.
_____________________________________________________________________
_______________________
Signature of Responsible Party (relationship)
Date

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