Patient Demographic Form Page 2
ADVERTISEMENT
1
2EMERGENCY / NEXT OF KIN CONTACT INFORMATION
Last Name
First Name
Middle Initial
Nickname/AKA
Home Address
Apt #
City
State
Zip Code
Home Phone
Work Phone
Other Phone
Cell Phone
INSURANCE INFORMATION
Primary Insurance Company
Policy #
Group #
Patient’s Relationship to Insured
Name of Subscriber
Subscriber’s Social Security #
Gender
Date of Birth
Employer of Subscriber
Work #
Male
Female
Secondary Insurance Company
Policy#
Group#
Patient’s Relationship to Insured
Name of Subscriber
Subscriber’s Social Security #
Gender
Date of Birth
Employer of Subscriber
Work #
Male
Female
AUTHORIZATION TO SHARE INFORMATION
The following people may know health information about you or obtain copies of your protected health information. If
patient is a minor, please list others that may accompany/transport/provide consent to treatment of the child when parent or
legal guardian is not available. You may change this list at any time in person, but people not included on this list will not be
allowed access to your health information.
Name:____________________________________________________ Relation:_________________________________
Name:____________________________________________________ Relation:_________________________________
Name:____________________________________________________ Relation:_________________________________
ASSIGNMENT OF INSURANCE BENEFITS
I hereby authorize the insurance carrier on the card photocopied by the receptionist at the front desk to make payments
directly to the health care provider and understand that I am financially responsible for all charges that are not covered in full
by my insurance. I further understand that if I enroll in another insurance plan or have a lapse in insurance coverage, that it is
my responsibility to notify the healthcare provider; otherwise I will be responsible for the payment. I understand that payment
is due at the time of service. I also understand that it is my responsibility to update my contact information as needed with the
office staff so that I can be contacted by my provider should the need arise.
_______________________________________________________________ _______________________________
Patient Signature
Date
Revised 09.21.2015
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical