New Patient Demographic and Insurance Form

Manhattan Primary Care

Bradley K. Harrison MD, FAAFP Kerri Maxcy PA-C Kyle E. Platz DO, FAAFP
New Patient Demographic and Insurance Form
Name *

First Name Middle Name Last Name
Preferred Name (Alias)
Date of Birth *

Month Day Year
Date
Social Security Number *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
Work Phone Number

Area Code Phone Number
Email
example@example.com
Responsible Party *

Self Other (complete information below)
Name: First Name   Last Name
   Same contact information as patient
Address: Street Address   Address Line 2   City   State   Zip
Phone (home)   Area Code   Phone Number
Phone (work)   Area Code   Phone Number
Phone (cell)   Area Code   Phone Number
Relationship to Patient:     Relationship to patient
Race *

Asian Black/African American White Prefer not to disclose
Ethnicity *

Not Hispanic/Latino Hispanic/Latino Prefer not to disclose
Primary Language *

English
Marital Status *

Married Single
Sex *

Male Female
Gender Identity *
Primary Insurance Provider: Insurance Provider*
Effective Date: Effective Date*
Who is the policy holder? Patient   Other Person
If Policy Holder is separate person, please provide the information below:
Name: First Name*   Last Name*
  DOB of policy holder: Date of birth of policy holder*
  Policy Holder Relationship to Patient: Policy Holder Relationship to Patient*
Secondary Insurance Provider (if applicable): Insurance Provider
Effective Date: Effective Date
Who is the policy holder? Patient   Other Person
If Policy Holder is separate person, please provide the information below:
Name: First Name   Last Name
  DOB of policy holder: Date of birth of policy holder
  Policy Holder Relationship to Patient: Policy Holder Relationship to Patient
Emergency Contact:
Name: First Name* Last Name* Phone Number: Phone Number*
Relationship: Relationship*
Please initial one of the following:
Initial I authorize Manhattan Primary Care to correspond with me with email that is not encrypted and not HIPAA Compliant.
Initial I authorize Manhattan Primary Care to ONLY use encrypted/HIPAA compliant email the correspond with me.
Please initial:
Initial* I have been given the opportunity to read the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Initial* I have read, understand, and agree to the Payment Policy outlined by Manhattan Primary Care (MPC).
Initial* I have been given the opportunity to read the vaccine policy outlined by Manhattan Primary Care.
Initial I do not authorize Manhattan Primary Care to leave health information message on any voice mail.
Initial I authorize Manhattan Primary Care to leave health information message on the below phone number(s).
   Area Code   Phone Number
   Area Code   Phone Number
   Area Code   Phone Number
Sharing of Medical Information. If left blank, we cannot share medical information with any person.
Initial I authorize Manhattan Primary Care to discussion my medical health information with Name, DOB, Relationship .

Initial I authorize Manhattan Primary Care to discussion my medical health information with Name, DOB ,
Relationship.
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

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Manhattan Primary Care

New Patient Demographic and Insurance Form