Patient Information

Patient's name*

First NameMiddle Name or InitialLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Cell phone (if none, enter home phone)*

Area CodePhone Number

Home phone

Area CodePhone Number

Work phone

Area CodePhone Number

Age:*

Social Security Number (not needed if you're an existing patient of ours)

Occupation

Company name

Spouse's/guardian's name

Spouse's/guardian's birth date

Spouse's/guardian's phone number

Area CodePhone Number

Spouse's/guardian's address (if different from patient's)

Spouse's/guardian's occupation

Spouse's/guardian's company

Your referring physician's name*

Office address (referring MD)

Phone number (referring MD)

Area CodePhone Number

PCP's name*

Office address (PCP)

Phone number (PCP)

Area CodePhone Number

Primary insurance plan*

Group or policy number*

ID or agreement number*

Policyholder*

SelfSpouse/Guardian

Insurance company's address (leave blank for Highmark or Medicare)

Insurance company's phone (leave blank for Highmark or Medicare)

Area CodePhone Number

Do you have secondary insurance?*

YesNo

Secondary insurance plan

Group or policy number (secondary)

ID or agreement number (secondary)

Policyholder (secondary)

SelfSpouse/Guardian

Secondary insurance company's address (leave blank for Highmark or Medicare)

Secondary insurance company's phone (leave blank for Highmark or Medicare)

Area CodePhone Number

Release and Assignment

I hereby consent to any necessary medical diagnosis and treatment for myself, child, or the above named minor for whom I am legally responsible. The release of medical information to any insurance carrier, and direct payment to this practice for any treatment or examination rendered is authorized. I hereby acknowledge and accept final responsibility for payment of the charges for medical services rendered.

By submitting the information below, you are electronically signing this form.

Patient's name*

Patient's birth date*

Your name and relationship, if you are the patient's personal representative