New Patient - Existing Patient Form

New Patient Information

Patient Update

Today's Date

Patient's Last Name

First Name

Middle

Preferred/Nickname

Marital Status (Check one)

Single

Married

Divorced

Widowed

Spouse/Parent (if minor) Name

Patient Social Security Number

Birthdate

Age

Home Address

City/State/Zip

Gender

M F

Cell Number

Emergency Contact Name and Number

Preferred Pharmacy

List anyone we can leave appointment information with other patient:

Relationship to patient and phone

Add Person

Responsible Party if Other Than Self/Insurance

DHR

Guardian

Other

Country/Person Responsible for Payment

Verified by Staff

Address

Insurance Information

Primary Insurance Company Name

Insurance Company Address

Policy Holder Name

Patient's Relationship to Policy Holder

Self Spouse Child Other

Policy Holder Birth Date

Policy Holder SSN

Contact Number

Group Number

Co-Payment

Policy Holder Employer Name

Employer Phone

Attach Copy of Card

Add file

Please upload a file

Secondary Insurance Company Name

Insurance Company Address

Policy Holder Name

Patient's Relationship to Policy Holder

Self Spouse Child Other

Policy Holder Birth Date

Policy Holder SSN

Contact Number

Group Number

Co-Payment

Policy Holder Employer Name

Employer Phone

Attach Copy of Card

Add file

Please upload a file

The above information is true and to the best of my knowledge. I authorize mu insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any balance due. I understand if my bill is transferred to a professional collection agency I will be charged an additional 33% of my outstanding balance as well as any collecting attorney fees. I also authorize Anniston Pediatrics, Inc. or insurance company to release any information required to process my claims. I understand that a copy of the Practice Information form for Anniston Pediatrics, Inc. is always available.

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.

Patient/Guardian Signature

Date

Staff Member

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