ANCZ01 Patient Information Form

PATIENT INFORMATION

Patient Name *

First Name

Middle Name

Last Name

Date of Birth *

Date

Social Security Number

Mailing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Please attach a photo of the patient’s government issued ID. If the patient is a minor, please attach a photo of the parent/guardian’s ID. Acceptable IDs include driver’s license, passport, military ID, etc. Please ensure that these IDs are valid and not expired. You can use your cell phone to take the picture.

📎

Select Image of Government Issued ID

or drag and drop files here

Allowed: jpg, jpeg, png, gif (max 5 MB)

Primary Phone Number

Please enter a valid phone number.

Is this your

Cell

Home

Alternate Phone Number

Please enter a valid phone number.

Is this your

Cell

Home

Email *

example@example.com

Employer

Occupation

How you heard about us (Radio/TV/Friend/Family, etc.)?

Sex

Male

Female

Are you a veteran?

Yes

No

Military

Active Duty

Retired

Marital Status

Married

Single

Widowed

Divorced

Spouse's Name

First Name

Last Name

May we contact?

Yes

No

Ethnicity

White or Caucasian

Black or African American

Asian

Native American or Alaska Native

Native Hawaiian or Other Pacific Islander

Other

Unknown

I decline to answer

Parent/Legal Guardian (if not patient)

First Name

Last Name

Emergency Contact

First Name

Last Name

Emergency Contact Phone Number

Please enter a valid phone number.

Emergency Contact Relationship to Patient

INSURANCE INFORMATION

Do you have primary insurance?

Yes

No

Primary Insurance

Insurance

Policy Holder

First Name

Last Name

Policy Holder's Social Security Number

Policy Holder's Date of Birth

Date

Policy Holder's Phone Number

Please enter a valid phone number.

Policy Holder's Email

example@example.com

Policy Holder's Employer

Insurance Phone Number

Please enter a valid phone number.

Policy Number

Group Number

Please attach a photo of the FRONT side of your PRIMARY insurance card. You can use your cell phone to take the picture.

📎

Select Insurance Card Image

or drag and drop files here

Allowed: jpg, jpeg, png, gif (max 5 MB)

Please attach a photo of the BACK side of your PRIMARY insurance card. You can use your cell phone to take the picture.

📎

Select Insurance Card Image

or drag and drop files here

Allowed: jpg, jpeg, png, gif (max 5 MB)

Do you have secondary insurance?

Yes

No

Secondary Insurance

Insurance

Policy Holder

First Name

Last Name

Policy Holder's Social Security Number

Policy Holder's Date of Birth

Date

Policy Holder's Phone Number

Please enter a valid phone number.

Policy Holder's Email

example@example.com

Policy Holder's Employer

Insurance Phone Number

Please enter a valid phone number.

Policy Number

Group Number

Please attach a photo of the FRONT side of your SECONDARY insurance card. You can use your cell phone to take the picture.

📎

Select Insurance Card Image

or drag and drop files here

Allowed: jpg, jpeg, png, gif (max 5 MB)

Please attach a photo of the BACK side of your SECONDARY insurance card. You can use your cell phone to take the picture.

📎

Select Insurance Card Image

or drag and drop files here

Allowed: jpg, jpeg, png, gif (max 5 MB)

PATIENT PAYMENT AGREEMENT

I understand that I am responsible for my medical bill and accept responsibility for any charges not covered and paid by my insurance company or other third party resources.

By signing below, I authorize the release of my medical records to the insurance carrier as may be necessary to determine benefits and to process claims for health care services provided to the above named patient.
I authorize assignment of Medicare/Medicaid, other federal/state agents or any commercial insurance carriers to pay benefits directly to the provider of service(s).
This is a Lifetime insurance authorization granting the provider authority to file claims on my behalf.

In addition to the above patient payment agreement, I sign below acknowledging receipt of the office’s NOTICE OF PRIVACY PRACTICES

** Your email address will only be used to provide you information about events and classes we are hosting/sponsoring. We will not share this information.

Digital Signature Authorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature *

Witness Signature

Date