Forms

Health Insurance Form

Patient’s Name (Last, First) _____________________________________________________

Second Patient’s Name (Last, First) _____________________________
Birth Date ________

Third Patient’s Name (Last, First) _______________________________
Birth Date ________

Patient’s Address _____________________________________________________________

Patient’s Phone: Home: ________________ Cell: ________________
Work:___ ___________

Date of Birth _________ Gender ______ Email; ________________________________

Is patient’s condition related to: Employment ___ Auto Accident __ Other Accident ___

Patient relationship to Insured: Self __ Spouse __ DP __Child__
Other ____________

Patient status:  
Single __ Married __ DP __ Separated ___ Employed ___ Student ____

Insured’s Name ____________________________

Insured’s I.D. Number ________________

Insured’s Address _____________________________________________________________

Insured’s Policy Group _______________
Insured’s Date of Birth _____________ Gender __

Name of Employer or School _____________________
Insurance Plan Name ___________

Is there another Insurance benefit plan? ___
Name of other plan: _______________________

I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment.  __________________________
Date ____________________

I authorize payment of medical benefits to the physician for services described.

Signature_______________________________ Date _____________________