ANCZ01 Patient Information Form

PATIENT INFORMATION
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number
Mailing Address

Street Address

Street Address Line 2

CityState / 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.

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Primary Phone Number
Please enter a valid phone number.
Is this your

CellHome
Alternate Phone Number
Please enter a valid phone number.
Is this your

CellHome
Email*
example@example.com
Employer
Occupation
How you heard about us (Radio/TV/Friend/Family, etc.)?
Sex

MaleFemale
Are you a veteran?

YesNo
Military

Active DutyRetired
Marital Status

MarriedSingleWidowedDivorced
Spouse's Name

First NameLast Name
May we contact?

YesNo
Ethnicity

White or CaucasianBlack or African AmericanAsianNative American or Alaska NativeNative Hawaiian or Other Pacific IslanderOtherUnknownI decline to answer
Parent/Legal Guardian (if not patient)

First NameLast Name
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Emergency Contact Relationship to Patient
INSURANCE INFORMATION
Do you have primary insurance?

YesNo
Primary Insurance
Insurance
Policy Holder

First NameLast Name
Policy Holder's Social Security Number
Policy Holder's Date of Birth

MonthDayYear
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.

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

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Do you have secondary insurance?

YesNo
Secondary Insurance
Insurance
Policy Holder

First NameLast Name
Policy Holder's Social Security Number
Policy Holder's Date of Birth

MonthDayYear
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.

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

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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*

Clear
Witness Signature

Clear
Date

MonthDayYear
Date
Should be Empty: