Patient Information Form

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Name *

First

Middle

Last

Address *

Address 2

City *

State *

Zip Code *

E-mail Address

Sex *

Date of Birth *

Social Security Number *

Marital Status

Employer

Occupation

with If below

Primary Care Physician

PCP Phone Number

Have you been diagnosed with any of the following:

If you are taking any medications, please list them below *

Insurance Provider *

Policy ID

Group Number (if available)

Are you the policy holder? *

Policy Holder's Name

Policy Holder's Social Security Number

Relationship to Patient

Insurance Statement *

I authorize the release of any medical information necessary to process this claim. I understand that if the payment of my benefits is denied, any balance due is the responsibility of the patient or guarantor.

HIPAA *

I acknowledge my rights under the Health Insurance Portability and Accountability Act (HIPAA). Our office has copies of the Notice of Privacy Practices at the front desk.