New Patient Information Form

New Patient Information Form
Patient Name*

First NameLast Name
Patient Gender*
Patient Birth Date*

MonthDayYear
Patient E-Mail
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Phone*

Area CodePhone Number
Alternate Phone

Area CodePhone Number
Insurance Information

Please provide accurate insurance information so that we may verify our providers are in network with your plan
Policy Holder*

First NameLast Name
Policy Holder Date of Birth*

MonthDayYear
Primary Insurance Plan Name*
Medicare, BCBS, United Healthcare, etc.
Primary Insurance Member ID*
Primary Insurance Group Number
Secondary Insurance Group Number
If no secondary insurance, leave blank
Secondary Insurance Plan Name
Secondary Insurance Member ID
Patient Medical History
Current Medical Problems/Reason for Seeing Doctor*
List of Current Medications*
If none, type n/a
Current Primary Care Physician
Or current specialist if you do not have a PCP
Do you have any history of TB?*

YesNoUnsure
Do you currently have a work or Motor Vehicle Accident (MVA) related injury or illness?*

YesNo
Preferred TIMA Physician*
Where did you hear about TIMA?
Internet, friends & family, physician referral, etc
Electronic Signature

Tyler Internal Medicine Associates requires that you certify your information by submitting an electronic signature. Please ensure all information above is accurate and correct, then type your name in the below.
Electronic Signature*

First NameLast Name
Should be Empty:

Insurance Information