Insurance Information

PRIMARY INSURANCE

Insurance Company:

Co-Pay:

Group #:

Subscriber #:

Insured First Name:

Last Name:

MI:

Social Security #:

Date of Birth:

Relationship to patient:

Address:

City:

State:

Zip:

Phone #:

EXT:

Advance Directive?

Yes No

If Yes, Where is it filed? (what medical facility?)

Insured employed by:

Business Address:

City:

State:

Zip:

Business Phone: #:

ADDITIONAL INSURANCE

Is the patient covered by additional insurance?

Yes No

Insurance Company:

Co-Pay:

Group #:

Subscriber #:

Insured First Name:

Last Name:

MI:

Social Security #:

Date of Birth:

Relation to Patient:

Address:

City:

State:

Phone:

EXT:

Insured Employed By:

Business Address:

City:

State:

Zip:

Business Phone #:

Occupation:

Business Name:

Business Phone:

Drivers License #:

State Issued:

Is this an accident?

Yes No

If Yes, Date of Injury:

Is this a motor vehicle accident?

Yes No

YOUR INSURANCE CARD AND PHOTO ID ARE REQUIRED AT THE TIME OF YOUR VISIT BY signing below, I attest that the information provided above is true and accurate.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Insured / Guardian:

Date:

Your information will be encrypted.