Patient Information Sheet

                Welcome to our Office…

                Attention: Please fill out this form COMPLETELY, write N/A where applicable and sign it.  Thank you.

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Social Security#

   

 

First Name:

_________________________________

Last Name:

______________________________

Middle Initial:

_________

Date of Birth: (MM/DD/YYYY)

_____ / _____ / _________

Gender:   

o Male      o Female

Marital Status:

o Single    o Married    o Other

Address: __________________________________

Apt.#:

____

City:

___________________

State:

___

Zip:

_______

Home Phone:

(_____) _____________________

Work Phone:

(_____) _____________________

Cell Phone:

(_____) _____________________

Emergency Contact:

__________________________________

Emergency Telephone#:

(_____) _____________________

Employer Name:

________________________________________

Employer’s Address / City / State / Zip

_________________________________________________

Referring Doctor:

______________________

Referring Dr.’s Address / City / State / Zip

___________________________________________

Ref. Dr. NPI #
______________________

Primary Care Physician:
______________________

Primary Care Physician’s Address / City / State / Zip

___________________________________________

P.C.P. NPI #
______________________

Primary Insurance Company Information:

Secondary Insurance Company Information:

Policy Holder First Name:

___________________________________________

Policy First Name:

______________________________________________

Policy Holder Last Name:

___________________________________________

Policy Holder Last Name:

______________________________________________

Policy Holders SS# 

______-_____-___________

Policy Holders Date of Birth:

____ / _____ / _____

Policy Holders SS# 

______-_____-____________

Policy Holders Date of Birth:

____ / _____ / ______

Gender:

 o Male      o Female

Relationship to Policy Holder:

          oSelf    oSpouse  oChild  oOther

Gender:

 o Male      o Female

Relationship to Policy Holder:

          oSelf    oSpouse  oChild  oOther

Policy Holder’s Address:     o Same as patient

__________________________________

Policy Holder’s Address:       o Same as patient

__________________________________

City:

____________________

State:

_____

Zip:

_____________

City:

______________________

State:

_____

Zip:

_____________

Insurance’s Name:

___________________________________________

Insurance’s Name:

___________________________________________

Policy ID:

_________________________

Group #:

________________

Policy ID:

___________________________

Group #:

________________

Claim Submission Address:

__________________________________________

Claim Submission Address:

______________________________________________

Effective Date: _____ / _____ / _______

Effective Date: _____ / _____ / _______

Do you have a Co-pay?   ¨ No    ¨ Yes, Amt $_______

Do you have a Co-pay?   ¨ No    ¨ Yes, Amt $_______

Referral Required:   ¨ Yes     ¨ No

Referral Required:   ¨ Yes     ¨ No
                                       

Responsible Party Information – Please complete if the responsible for payment is not the Patient or the Policy Holder.

Responsible Party’s Name (Last / First):

_____________________________________

Responsible Party’s SSN:

___-__-_____

Relationship to Responsible Party:

        oSelf    oSpouse  oChild  oOther

Responsible Party’s Address / City / State / Zip:

________________________________________________________________________________________________________________________________________

FINANCIAL POLICY

I hereby authorize the release of any medical information necessary to process this claim and hereby assign to the physician all payments for medical services rendered to my dependents or myself. I understand that it is as a courtesy that the doctor accepts my insurance for payment and that if for any reason they do not pay my bill that I am responsible.

The Practice accepts personal checks. In the event that a check ‘bounces’ (i.e., insufficient funds exist to cover the check), a fee of $25 will be applied.

All patients receive a reminder call for upcoming appointments. Failure to appear or call to cancel 24hrs prior to an appointment (no show) will result in a $25 fee.

By signing below, I acknowledge and agree to abide by this policy. I also acknowledge that I have been given the opportunity to review the Health Insurance Portability and Accountability Act (HIPPA) Notice of Privacy Practices and I agree to comply with all of its terms.

  

Today’s Date:_________________      Patient’s Signature (or parents if under 18 years of age): _____________________________
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