New Patient Demographic Information

Today's Date: (mm/dd/yyyy)

Chart # ____________________________
 

PATIENT INFORMATION :

 

Full Name: (first), (middle) , (last)

Sex: Male female Birthdate: (mm/dd/yyyy) Social Security #:

Address:

Street:

Home Phone: Work Phone:

Contact Phone:

City, State, Zip:

Employer:

Marital Status: Single ....... Married ....... Divorced ....... Other

In case of emergency, please notify:
(not living at same address as patient) Phone:

 

GUARANTOR INFORMATION: (Responsible Party) - (Will be SELF if patient is 18 years of age or older)

Full Name: (first), (middle) , (last)

Address:

Street:

SEX: Male Female Birthdate: (mm/dd/yyyy)

Social Security#:

City, State, Zip:

Driver's License #:

Home Phone: Work Phone:

Employer:

 

INSURANCE INFORMATION (INSURANCE CARD REQUIRED TO FILE INSURANCE)

Primary Insurance:

Address:

Street:

Pt. Relation to Insured:

City, State, Zip:

Insurance Phone # ( )

Effective From (mm/dd/yyyy):

 

Policy Holder's Name:

Policy #:

Policy Holder's Birthdate: (mm/dd/yyyy)

Group #:

Policy Holder's Employer:

Social Security #:

 

Employer Address:

 

CONSENT TO TREAT, ASSIGNMENT OF BENEFITS, AND RELEASE OF INFORMATION TO INSURANCE COMPANIES

Please initial each box

( ___________ ) I CONSENT TO TREATMENT NECESSARY FOR THE CARE OF THE PATIENT INDICATED ON THIS FORM. I UNDERSTAND THIS FACILITY MAY EMPLOY PHYSICIAN EXTENDERS.
( ___________ ) I HEREBY AUTHORIZE PAYMENT OF MEDICAL BENEFITS DIRECTLY TO THE ATTENDING PHYSICIAN FOR SERVICES RENDERED. AUTHORIZATION IS HEREBY GRANTED TO RELEASE INFORMATION AS MAY BE NECESSARY TO PROCESS AND COMPLETE MY CLAIM. I UNDERSTAND I AM FINANCIALLY RESPONSIBLE FOR THIS ACCOUNT.

 

Date: ______________________ Signature: ______________________________