BALZ05 Patient Demographics Form

Patient Demographics Form

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Full Legal Name *

First Name

Middle Name

Last Name

Preferred Name

Date of Birth *

Date

Gender

Male

Female

Non-binary

Other

Marital Status

Single

Married

Divorced

Widowed

Other

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Email

example@example.com

Please attach a photo of the patient’s government issued ID (driver’s license, passport or 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)

Emergency Contact

Name

First Name

Last Name

Phone Number

Please enter a valid phone number.

Relationship

Insurance Information

Do you have insurance?

Yes

No

Primary Insurance Company

Policy Holder Name

First Name

Middle Name

Last Name

Policy Number

Group Number

Relationship to patient

Self

Spouse

Parent

Other

Policy Holder Date of Birth

Date

To expedite your benefits confirmation, 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)

To expedite your benefits confirmation, 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 Company

Secondary Policy Holder Name

First Name

Middle Name

Last Name

Secondary Policy Number

Secondary Group Number

Relationship to patient

Self

Spouse

Parent

Other

Secondary Policy Holder Date of Birth

Date

To expedite your benefits confirmation, 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)

To expedite your benefits confirmation, 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)

Preferred Pharmacy

Name

Phone Number

Please enter a valid phone number.

Address or Cross Streets

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 *