Patient Information Form

Last Name:

First Name:

Middle Name:

Address:

City:

State:

Zip:

Mailing Address:

City:

State:

Zip:

Home Phone #:

Cellphone #:

Work Phone #:

Ext:

Date of Birth:

Social Security #:

Email Address:

Pharmacy:

Employer:

Sex:

Male Female Transgender

Marital Status:

Single Married Divorced Widowed

Please Choose One:

Prefer Messages:

Morning Afternoon Evening

Race:

Asian-Native Hawaiian White Hispanic Black or African American Other Refuse to Answer

Ethnicity:

Hispanic or Latino Not Hispanic or Latino Refuse to Answer

Primary Care Physician:

Referring Doctor:

Responsible Party (If Patient is a Minor)

Name:

Date of Birth:

Address:

City:

State:

Zip:

Phone #:

Social Security #:

Relation to Patient:

Policy Holder (If Different from Patient)

Name:

Date of Birth:

Address:

City:

State:

Zip:

Social Security #:

Phone #:

Employer:

Relation to Patient:

Emergency Contact Information

Name:

Phone #:

Address:

State:

City:

Zip:

Relation to Patient:

Will the Emergency Contact be allowed access to the patient's Medical Information/HIPAA?

Yes No

Insured Information (If Insured Only)

Insurance Company:

Phone #:

Address:

City:

State:

Zip:

Group #:

Policy #:

Member ID #:

Insurance Company:

Phone #:

Address:

City:

State:

Zip:

Group #:

Policy #:

Member ID #:

Assignment of Insurance Benefits: In the event that the undersigned is entitled to benefits of any type as part of any insurance policy covering patient or any other party liable to patient said benefits are hereby assigned to ENTA for application to patient's bill. The undersigned shall be responsible for any and all charges not covered by such an insurance policy or policies.

Financial Agreement: The undersigned agrees, whether signing as a patient or an agent, that in consideration of the services to be rendered to the patient he / she hereby individually obligates himself / herself to pay any balance outstanding after reassignment and payment of insurance benefits. Should the account be referred to an outside agency for collection, the undersigned shall pay reasonable collection and / or attorney expenses. In the event of cash payment for services or if patient is to self-pay, payment in full is due at the time services are rendered.

Release Information: ENTA may disclose all or any part of patient's record to any individual or corporation which is or may be liable under a contract with ENTA, to the patient or to a family member or employer of the patient for all or part of ENTA's charges, including but not limited to: hospital or medical service companies, insurance companies, worker's compensation carriers, welfare or public assistance funds, private foundations or charitable organizations, or the patient's or guarantor's employer/s. ENTA shall comply with Federal Privacy Act and HIPAA and shall not disclose patient information to parties not authorized to receive such information under these regulations.

I attest that the information I have provided to ENTA is true and accurate and I agree to the terms outlined above.

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

Patient or Guarantor Signature:

Date:

Your information will be encrypted.