Mobile Unit Lead Testing Intake Form

PATIENT INFORMATION

Last Name:

First Name:

MI:

Social Security Number:

Date of Birth:

U.S. Military Service (Select One:)

None Currently Serving Discharged

Address:

City:

State:

Zip Code:

Country:

Home Phone:

Work Phone:

Cell Phone:

Email:

Gender (Select One):

Male Female

Primary Language Spoken:

Limited English

Patient’s Relationship to Responsible Party (Select One):

Self Spouse Natural Child Parent Foster Child Foster Parent

Are you a migrant/seasonal worker or a family member of a migrant/seasonal worker?

Yes No

What is your annual income?

$0 - $15,060 $15,061 - $18,825 $18,826 - $22,590 $22,591 - $26,355 $26,356 - $30,120 $30,121 & UP

Number of people in household

Emergency Contact:

Phone:

Relationship to Patient:

RESPONSIBLE PARTY INFORMATION

(Enter name of person FINANCIALLY responsible for your account)

Last Name:

First Name:

MI:

Mailing Address:

City:

State:

Zip Code:

Country:

Home Phone:

Work Phone:

Cell Phone:

Date of Birth

Social Security Number:

INSURANCE COMPANY – INCLUDING MEDICAID

Primary Insurance:

ID#:

Group#:

Insurance Company Address:

Name of Insured:

Date of Birth:

Insured’s Employer:

Relationship to Responsible Party:

Self Spouse Natural Child Step Child Parent Foster Child Foster Parent

Assignment and Release

I authorize my insurance benefits to be paid directly to PanCare Health. I also authorize PanCare Health to release any information required to process this claim.

SIGNATURE:

DATE:

Consent for Treatment

I hereby authorize PanCare Health, its facilities and treatment centers, its affiliated providers, dentists, dental hygienists, nurse practitioners, physician assistants, psychologists, social workers, and other medical personnel to administer examinations and treatments as deemed medically necessary.

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.

Parent/Guardian Signature

Date:

Your information will be encrypted.