new-patient-paperwork-spanish

PATIENT INFORMATION NAME (Last, First Middle)

SSN#

LOCAL ADDRESS

CITY, STATE, ZIP

HOME PHONE MARITAL STATUS

SMOKER?(Y/N)

SEX

SECONDARY/BILLING ADDRESS (If applicable)

CELL PHONE STUDENT STATUS

BIRTHDATE

CITY, STATE, ZIP VETERAN? (Y/N)

PRIMARY CARE PROVIDER

EMERGENCY CONTACT NAME AND PHONE NUMBER

EMAIL ADDRESS

HOW DID YOU HEAR ABOUT OUR OFFICE?

WITH WHOM MAY WE DISCUSS YOUR MEDICAL INFORMATION? (PLEASE WRITE OUT SPOUSE, PARENT, ONLY ME, OR OTHER NAME)

PATIENT EMPLOYER

SPOUSE EMPLOYER

ADDRESS

ADDRESS

CITY, STATE, ZIP

CITY, STATE, ZIP

WORK PHONE

OCCUPATION

WORK PHONE

OCCUPATION

INFORMATION OF PRIMARY SUBSCRIBER ON INSURANCE NAME (Last, First Middle)

SSN#

LOCAL ADDRESS

CITY, STATE, ZIP

HOME PHONE MARITAL STATUS

CELL PHONE STUDENT STATUS

SMOKER?(Y/N)

SECONDARY/BILLING ADDRESS (IF APPLICABLE)

WORK PHONE

CITY, STATE, ZIP

VETERAN? (Y/N)

RELATIONSHIP TO PATIENT

BIRTH DATE

PRIMARY CARE PROVIDER

EMPLOYER / OCCUPATION

PRIMARY INSURANCE INFORMATION NAME OF INSURANCE COMPANY

POLIICY #

NAME OF INSURED

GROUP#

ADDRESS OF INSURANCE COMPANY

COPAY AMOUNT

CITY, STATE, ZIP RELATIONSHIP TO PATIENT

PHONE # EFFECTIVE DATE

DEDUCTIBLE EXPIRATION DATE

SECONDARY INSURANCE INFORMATION NAME OF INSURANCE COMPANY

POLIICY #

NAME OF INSURED

GROUP#

ADDRESS OF INSURANCE COMPANY

COPAY AMOUNT

CITY, STATE, ZIP RELATIONSHIP TO PATIENT

PHONE # EFFECTIVE DATE

DEDUCTIBLE EXPIRATION DATE

EMAIL ADDRESS

SEX I understand that MomDoc Women for Women participates in many insurance plans. If I am not sure if my insurance is one of those accepted, I should call my plan and inquire if MomDoc Women for Women are part of my network. I understand that it is my responsibility to get any needed referrals before my visit. I understand that it is my responsibility to know and understand my benefits and coverage. I understand that I may request a refund of any credits on my account once all claims have been processed and paid. I understand that all professional services rendered are charged to me, and that I am responsible for all fees, regardless of insurance coverage. I understand that it is customary for payment to be made when services are rendered unless other arrangements have been made in advance with an office manager. I understand that all co-pays are expected before being seen. I understand that reasonable late fees or collections fees may be assessed in the event of late payment or nonpayment of balance. I request that payment of authorized Medicare/insurance company benefits be made either to me or on my behalf to MomDoc Women for Women for any services furnished me by that party who accepts assignment/physician. Regulations pertaining to Medicare assignments of benefits apply. I authorize any holder of medical information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carriers any information needed for this or a related Medicare claim or insurance claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or to the party who accepts assignment. I understand it is mandatory to notify the health care provider of any other party who may be responsible for paying for my treatment. Section 1128B of the Social Security Act and 31 U.S.C 3801-3812 provide penalties for withholding this information.) I have read, understand and have been offered a copy of the Notice of Privacy Practices for Protected Health Information.

DATE_______________________________________ PATIENT NAME_______________________________ DOB________________________________________ SIGNATURE__________________________________