Insurance Intake Form printable pdf download

Insurance Intake Form

Patient Name___________________________________ Date of Birth_____/______/_______

Age_________

Male/Female

Street Address_______________________________________SS#_____________________

City____________________________ State________ Zip___________

Marital Status: Single Married Separated Divorced Widowed

Phone:

Home_____________________Work______________________Cell_________________

Referred by: _______________________________________

Responsible Party (if different from above)

Address_______________________________________________________________________

Phone_________________________________________________________________________

Emergency Contact_________________________ Phone__________________

Relationship_________________

Primary Insurance Company__________________________________________________

Policy Holder ___________________________DOB: ______________

Social Security #__________________________________________

Policy Number____________________________________________

Group Number____________________________________________

Relation to Patient_________________________________________________

Employer Name____________________________________________________

Employer City/State: ______________________________________________

Copay/Coinsurance______________________Deductible_______________________

Deductible met? YES NO

Is patient covered by another insurance policy? NO YES - If yes, please enter name of second

company below: Secondary Insurance

Company____________________________________________________________________

(Please note that we do not file secondary insurance claims, but can give you a receipt for you to

file.)

Primary Care Physician: ________________________________

Phone_______________________________________________

Insurance Intake Form