1. Patient Personal Information
Full legal name (Last, First, Middle)
*
Date of birth
*
Sex (for billing)
*
Male
Female
Other
Social Security Number
*
Required by your insurance carrier for claim processing.
Insurance card — FRONT side
*
Insurance card — FRONT side
Insurance card — BACK side
*
Insurance card — BACK side
Street address (include Apt/Unit #)
*
City
*
State
*
ZIP code
*
Home phone
*
Type N/A if this does not apply to you.
Cell phone
*
Email address
*
Preferred language
*
2. Primary & Secondary Health Insurance
Primary insurance provider
*
Policy holder / subscriber name
*
Subscriber date of birth (MM/DD/YYYY)
*
Relationship to patient
*
Self
Spouse
Child
Other
Member ID / policy number
*
Group number
*
Type N/A if this does not apply to you.
Secondary insurance provider
*
Type None if you do not have secondary insurance.
Secondary member ID & group
*
Type None if you do not have secondary insurance.
3. Accident & Third-Party Liability Injury Section
Is this medical visit due to an accident or injury?
*
Yes
No
If yes, complete sections 4 or 5 below.
Type of accident
*
Work-related / Workers' Comp
Automobile accident
Personal injury / other liability
Not applicable - not an accident
Date of injury / accident
*
MM/DD/YYYY. Type N/A if this does not apply to you.
State where accident occurred
*
Type N/A if this does not apply to you.
Body part(s) / injury area
*
e.g. Lower Back, Neck. Type N/A if this does not apply to you.
4. Worker's Compensation Claims
Employer at time of injury
*
Type N/A if this does not apply to you.
Employer HR / contact phone
*
Type N/A if this does not apply to you.
Workers' comp insurance carrier
*
Type N/A if this does not apply to you.
Claim number / case ID
*
Type N/A if this does not apply to you.
Assigned claims adjuster name
*
Type N/A if this does not apply to you.
Adjuster phone & email
*
Type N/A if this does not apply to you.
5. Auto Accident & Third-Party Liability Claims
Auto insurance carrier name
*
Type N/A if this does not apply to you.
Billing address for auto carrier
*
Type N/A if this does not apply to you.
Policy number
*
Type N/A if this does not apply to you.
Claim number
*
Type N/A if this does not apply to you.
Liability adjuster name & phone
*
Type N/A if this does not apply to you.
Is an attorney representing you?
*
Yes
No
Not applicable
Law firm / attorney name
*
Type N/A if this does not apply to you.
Attorney direct phone line
*
Type N/A if this does not apply to you.
6. Emergency Contact Information
Primary contact name
*
Relationship to patient
*
Primary contact phone
*
Alternate phone
*
Type N/A if this does not apply to you.
7. Required Disclosures, Authorizations & Signatures
Do you agree to the HIPAA Acknowledgment above?
*
I acknowledge the Notice of Privacy Practices
Do you agree to the Assignment of Benefits above?
*
I agree to the Assignment of Benefits and Financial Responsibility
Do you agree to the Medical Lien & Accident Authorization above?
*
I authorize the Medical Lien & Accident Authorization
Patient / authorized guarantor signature
*
Type your full legal name. This serves as your electronic signature and confirms your agreement to the disclosures above.
Date (MM/DD/YYYY)
*
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