Today’s
Date _____/_____/_____ |
PCP_______________________________ |
PATIENT INFORMATION |
Patient’s Last
Name First Middle |
q Mr. q Mrs. |
Marital Status
(Circle One) |
|
q Miss q Ms. |
Single / Mar / Div / Sep / Wid |
Is this your
legal name? |
If not, what
is your legal name? |
(Former Name) |
Birth Date |
Age |
Sex |
q Yes q No |
|
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/ / |
|
q M q F |
Street Address |
City |
State |
ZIP Code |
Social Security |
Home Phone
No. |
|
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( ) |
P.O. Box |
City |
State |
ZIP Code |
|
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Occupation |
Employer |
Employer Phone
No. |
|
|
( ) |
Chose
Clinic Because/Referred to Clinic by (Please check one box) |
q Dr. |
q Insurance
Plan |
q Hospital |
q Family |
q Friend |
q Close
to Home/Work |
q Yellow
Pages |
q Other
________________ |
|
Other
Family Members Seen Here |
|
|
INSURANCE INFORMATION |
(please give your insurance card to
the receptionist) |
Person Responsible
for Bill |
Birth Date |
Address (if different) |
Home Phone No. |
|
/ / |
|
( ) |
Is
this person a patient here? |
q Yes q No |
|
Occupation |
Employer |
Employer Address |
Employer Phone
No. |
|
|
|
( ) |
Is
this patient covered by insurance? |
q Yes q No |
|
Please indicate
primary insurance |
q Blue
Choice |
q Preferred
Care |
q No
Fault |
q Worker’s
Compensation |
q Aetna |
q United |
q Blue
Cross/ Blue Shield |
q Via
Health |
q Medicare |
q Other ______________ |
(Please
provide coupon) |
|
Subscriber’s
Name |
Subscriber’s
S.S. # |
Birth Date |
Group # |
Policy # |
Co-Payment |
|
|
/ / |
|
|
$ |
| Patient’s Relationship to Subscriber |
q Self q Spouse q Child q Other ______________ |
|
| Name of Secondary Insurance (if applicable) |
Subscriber’s
Name |
Group # |
Policy # |
|
|
|
|
Patient’s
Relationship to Subscriber |
q Self q Spouse q Child q Other ______________ |
|
IN CASE OF EMERGENCY |
Name of Local Friend
or Relative
(not living at same address) |
Relationship
to Patient |
Home Phone
No. |
Work Phone
No. |
|
|
( ) |
( ) |
The above
information is true to the best of my knowledge. I authorize my insurance
benefits be paid directly to the physician. I understand that I am financially
responsible for any balance. I also authorize HealthSource Chiropractic
or insurance company to release any information required to process my
claims. |
X |
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PATIENT/GUARDIAN
SIGNATURE |
DATE |
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