Demographics Sheet

Patient Information

Name

Address

City

State

Zip

Phone(s)

Date of Birth

Age

Sex

Race

Ethnicity

Language

Insurance Information

Primary Insurance

ID Number

Group Name & Number

Subscriber Name

Subscriber Date of Birth

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(Tricare Insured Only)Active Duty

Yes No

Type

S.S. OR Benefit #

Sponsor Name

Sponsor Date of Birth

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Insured’s Employer

Employer Name

Phone

Address

City

State

Zip

Patient’s Parent/Guardian Guarantor/Responsible Party for Billing

Name

Phone(s)

Address

City

State

Zip

Relationship to Patient

Date of Birth

Email Address

Patient’s Parent/Guardian

Name

Phone(s)

Address

City

State

Zip

Relationship to Patient

Date of Birth

Emergency/Alternate Contact

Name

Phone(s)

Address

City

State

Zip

Siblings to Patient (name & date of birth)

RELEASE OF INFORMATION

I hereby authorize Mary Ann Ellis-Jammal, M.D. to furnish and disclose all known facts concerning my care to my insurance company other physicians, or persons / facilities upon my request.

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.

Date

Signature

ASSIGNMENT OF BENEFITS

I hereby authorize, to make payment directly to Mary Ann Ellis-Jammal, M.D. of any insurance benefits otherwise payable to me for her professional services rendered to date and not to exceed the stated charges for these services. I understand that I am responsible for any charges not paid by my insurance company or for any charges not paid within 90 days of billing to said insurance company. A copy of this authorization shall be valid as the original.

Date

Signature

Please upload the front and back of the insurance card.

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