Adult Patient Information

* required field

Patient Information

Patient Name *

Male Female

Social Security Number

Birth Date *

Home Address *

State *

Zip *

Primary Phone Number *
Phone Type *
HomeCell

E-mail Address *

Insurance Information

Primary Insurance Company

Group Number

Member ID Number

Policy Holder's Name

Relation

Policy Holders Social Security Number

Policy Holder's Birth Date

Employer

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.

Patient Signature and/or Responsible Party

Date

Security Measure