Demographic Form

PATIENT INFORMATION

Name

MRN

SSN

Birth Date

Language

Sex

Local Address

City, State, Zip

Home Phone

Secondary/Billing Address (if applicable)

City, State, Zip

Secondary Home Phone

Ethnicity

Race

Primary Care Physician

Referring Physician

Contact Name

Contact Home Phone

Sexual Orientation

Preferred Pronoun

Gender Identity

Current Gender

Primary Employer

Secondary Employer (if applicable)

Address

City, State, Zip

Work Phone

City, State, Zip

Work Phone

RESPONSIBLE PARTY INFORMATION (Different than above)

Name

SSN #

Birth Date

Language

Sex

Local Address

City, State, Zip

Home Phone

Secondary/Billing Address (if applicable)

City, State, Zip

Secondary Home Phone

Relationship to Patient

PRIMARY INSURANCE

Name of Insurance Company

Policy #

Name of Insured

Group #

Address of Insurance Company

Copay Amt

City, State, Zip

Deductible Amt

Relationship to Patient

Effective Date

Expiration Date

SECONDARY INSURANCE (If applicable)

Name of Insurance Company

Policy #

Name of Insured

SSN #

Birth Date

Group #

Address of Insurance Company

Copay Amt

City, State, Zip

Deductible Amt

Relationship to Patient

Effective Date

Expiration Date

I certify that the information I have provided is correct and I authorize Capital Women’s Care to verify insurance coverage and benefits allowed in accordance with my insurance plan's coverage I authorize payments be made directly to Capital Women's Care for all medical insurance benefits which are payable under the terms of my insurance policy for services provided. I agree to pay any copayment, coinsurance, or deductible as required by my insurance for services provided to me or my dependent. I understand that I am responsible for knowing the terms of my insurance plan. Capital Women's Care may impose a no-show fee of $35 for appointments not canceled 24-hours in advance.

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

Date

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