Patient Information Sheet

NAME (LAST) _______________________ (FIRST) ___________________(INITIAL) ______

(As Listed With Your Insurance)

PHONE (HOME) __________________________ (WORK) _________________________________

ADDRESS:

STREET: _____________________________ PO BOX/STREET ___________________________

CITY: ______________ _________________ CITY: __________________________________

STATE: _____________ZIP:______________ STATE: ____________ ZIP: _______________

Patient’s Date of Birth: ______________________ Subscriber’s Employer:___________

Subscriber’s Employer Address:___________________________________________________

Patient’s Occupation:______________________ ______________________________________

Patient’s Legal Status: (circle one) S • M • Sep • D • W

Emergency Contact: ______________________________ Phone: _________________________

Relationship to Patient:__________________________________________________________

Nearest of Kin: __________________________________ Phone: _________________________

(If under 18 years) Relationship to Patient:______________________________________

Person To Receive Bill: ___________________________ Phone:_________________________

Address ___________________________________________________________________________

(If different from above.)

Primary Care Physician: ____________________________________________________________

HEALTH INSURANCE:

Name of Your Insurance: _________________________ Medicare:# _______________________

Insurance Address: ____________________________ Medex:# ____________________________

(If on back of card.)____________________________ State: ___________________________

Subscriber: ___________________________________ Copay:______________________________

Patient’s ID#: __________________________________ Group #: _________________________

(On insurance card) (If on insurance card.)

No Insurance (Circle if applicable)

I hereby authorize my insurance benefits to be paid directly to _____________________

for the medical services rendered. I also authorize _________________________________

to release any information necessary to process this claim.

Signature: ___________________________ Date: ________________________________________