Patient Information Form - Lockhart Family Medicine

Patient's Name

Birthdate

Age

Mailing Address

Apt. #

City

State

Zip Code

Home Phone

Driver's License #

Email address

Race / Ethnicity

Preferred Language

Cell Phone #

Patient's Employer or School Name

Occupation

Work Phone #

Spouse's Name

Occupation (Indicate if student)

Home Phone #

Email address

Cell Phone #

Work Phone #

Emergency Contact Name

Mailing Address

Home Phone #

Relationship to Patient

Cell Phone #

Work Phone #

Drug Allergies

RESPONSIBLE PARTY

Parent or Guardian of a minor (under 18 y/o dependent child)

1st Guardian's Name & Relationship

Occupation (Indicate if student)

Home Phone #

Mailing Address

Apt. #

City

State

Zip

Work Phone # (Ext.)

1st Guardian's Employer

Driver's License #

Cell Phone No.

2nd Guardian's Name & Relationship

Occupation (Indicate if student)

Home Phone #

Mailing Address

Apt. #

City

State

Zip

Work Phone # (Ext.)

2nd Guardian's Employer

Driver's License #

Cell Phone No.

INSURANCE INFORMATION

Primary Insurance

Effective Date

Name of Policy Holder

Date of Birth

Id #

Group #

Policy Holder Address

City

State

Zip

Policy Holder's Phone #

Secondary Insurance

Effective Date

Name of Policy Holder

Date of Birth

Id #

Group #

Policy Holder Address

City

State

Zip

Policy Holder's Phone #

CONSENT FOR MINORS OR DEPENDENT ADULTS

THIS CONSENT REMAINS IN PLACE UNTIL REVOKED IN WRITING OR CHILD IS NO LONGER A MINOR Who may bring the child in for treatment or followup other than the legal parent?

Additional Name

CONSENT FOR MINORS

I hereby give my consent for Lockhart Family Medicine to evaluate and treat the patient of this form.
I have been provided with the Privacy Practicers Notice for Lockhart Family Medicine.
I understand that my personal health information will be used for the purpose of treatment, payment, and the coordination of the health care needs of the patient.

ASSIGNMENT OF INSURANCE BENEFITS

Payment is due at the time services are rendered. I understand that I am responsible for any health insurance deductibles, co-payments, or coinsurance. I understand that should membership verification not indicate coverage, I agree to pay in full for services rendered. I agree that billing information and address information is correct as shown on the front of this document. I authorize payment of medical benefits to Lockhart Family Medicine for services rendered.

We have contracted with several insurance plans in order to accommodate your needs. While we are happy to provide this service to you, it is impossible for us to know the individual provisions of every patient's plan. The policy book you have received when you signed up for your insurance outlines the specifics of your plan.

It is your responsibility to read and understand your plan's provisions. If you have questions about your insurance coverage, call your insurance company or employer for clarification prior to your appointment.

When you see us for each visit you must let us know what the guidelines for your insurance coverage are. For example, if your plan requires you to use a specific lab or radiology facility, it is your responsibility to let us know which one.

AUTHORIZATION TO RELEASE INFORMATION

I authorize the release of any medical or other information necessary to process this claim. Lockhart Family Medicine recognizes that information regarding my health care is confidential. Unless I request otherwise, Lockhart Family Medicine will only release my health care information as specified by state law. I understand that I have the right to obtain copies of my health care information for a fee.

give my permission to Lockhart Family Medicine and staff to release medical information contained in my medical file about myself to those indicated below.

Add Additional Name

AUTHORIZATION TO TREAT

I hereby authorize treatment by Lockhart Family Medicine and the office staff.
A PHOTOCOPY OF THESE ASSIGNMENTS SHALL BE AS VALID AS THE ORIGINAL

I have read and understood these office policies and agree to accept the responsibilities as described.

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 patient or responsible party

Date

Your information will be encrypted.