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Thread 2937238 - Clone of New patient intake form NEW Version
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42
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1
Please enter your name
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First Name
Middle Name
Last Name
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2
Date of Birth
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Date
Month
Day
Year
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3
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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4
Primary Phone
*
This field is required.
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5
Home
Not required
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6
Work
Not required
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7
Email
*
This field is required.
If you don't have an email address, please enter "example@example.com"
example@example.com
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8
Would you like to get an email, text or automated phone call as an automated reminder?
*
This field is required.
The reminder comes approximately 24 hrs. prior to your appointment
Email
Text Message
Automated phone call
None
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9
How did you hear about us?
If you choose "Other", you are able to type comments in the box.
MD
Insurance
Friend
Internet
Other
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10
In the event of an emergency, who would you like us to contact?
First Name
Last Name
Relationship
Please enter phone number
Please enter phone number
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11
Is your injury related to any of the following?
*
This field is required.
If related to an accident, please contact the office if the circumstances have not already been reviewed.
Automobile Accident
Employment Accident
Other Accident Related
None of the Above
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12
Have you had any prior Physical Therapy/Occupational/Speech Therapy this calendar year?
Choose One
No
Yes ( indicate below # of visits used)
Choose One
Choose One
No
Yes ( indicate below # of visits used)
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13
Describe your pain?
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14
Where is you pain?
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15
Pain Scale Last 24 Hours (0 to 10)
0
1
2
3
4
5
6
7
8
9
10
Worst level of pain? (0-10)
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Row 0, Column 7
Row 0, Column 8
Row 0, Column 9
Row 0, Column 10
Current level of pain? (0-10)
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Row 1, Column 6
Row 1, Column 7
Row 1, Column 8
Row 1, Column 9
Row 1, Column 10
Best level of pain? (0-10)
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Row 2, Column 6
Row 2, Column 7
Row 2, Column 8
Row 2, Column 9
Row 2, Column 10
Worst level of pain? (0-10)
Current level of pain? (0-10)
Best level of pain? (0-10)
0
Row 0, Column 0
1
Row 0, Column 1
2
Row 0, Column 2
3
Row 0, Column 3
4
Row 0, Column 4
5
Row 0, Column 5
6
Row 0, Column 6
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Row 0, Column 7
8
Row 0, Column 8
9
Row 0, Column 9
10
Row 0, Column 10
0
Row 1, Column 0
1
Row 1, Column 1
2
Row 1, Column 2
3
Row 1, Column 3
4
Row 1, Column 4
5
Row 1, Column 5
6
Row 1, Column 6
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Row 1, Column 7
8
Row 1, Column 8
9
Row 1, Column 9
10
Row 1, Column 10
0
Row 2, Column 0
1
Row 2, Column 1
2
Row 2, Column 2
3
Row 2, Column 3
4
Row 2, Column 4
5
Row 2, Column 5
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Row 2, Column 6
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Row 2, Column 7
8
Row 2, Column 8
9
Row 2, Column 9
10
Row 2, Column 10
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16
Have you fallen in the past year?
Choose one
No
Yes ( Indicate # of falls in the box below)
Choose one
Choose one
No
Yes ( Indicate # of falls in the box below)
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17
Are you currently, or have you previously been, diagnosed with any of the following? (Please check all that apply and scroll to see all conditions):
If you choose "Other", you are able to type comments in the box.
None of the Above
Arthritis
Diabetes Type 1
Atrial Fibrillation
Diabetes Type 2
Cancer
Muscular Dystrophy
Joint Replacement
History of Fracture
Shoulder Problems
Infection
Heat Attack
High Blood Pressure
Thyroid Disorder
Stroke
Other
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18
List any surgeries:
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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19
Have you had any test done related to your symptoms?
If you choose "Other", you are able to type comments in the box.
MRI
X-Ray
CT Scan
Ultrasound
Blood Test
Other
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20
Do you have a printed list for the medication?
YES
NO
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21
Bring your list on the appointment
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22
Medication, Vitamins & Supplements (If you have a medication list, please bring to your appointment)
Please list all medications including frequency and dosage (both over-the-counter and prescribed). If completing on a phone use blue arrow to add >1. If using tablet/computer scroll to add more.
Name of Medication
Dosage
Frequency
Route of Administration
1
Row 0, Column 0
Row 0, Column 1
1x a day
2x a day
3x a day
As needed
1x a day
2x a day
3x a day
As needed
Row 0, Column 2
Oral
Sublingual
Topical
Subcutaneous Injections
Oral
Sublingual
Topical
Subcutaneous Injections
Row 0, Column 3
2
Row 1, Column 0
Row 1, Column 1
1x a day
2x a day
3x a day
As needed
1x a day
2x a day
3x a day
As needed
Row 1, Column 2
Oral
Sublingual
Topical
Subcutaneous Injections
Oral
Sublingual
Topical
Subcutaneous Injections
Row 1, Column 3
3
Row 2, Column 0
Row 2, Column 1
1x a day
2x a day
3x a day
As needed
1x a day
2x a day
3x a day
As needed
Row 2, Column 2
Oral
Sublingual
Topical
Subcutaneous Injections
Oral
Sublingual
Topical
Subcutaneous Injections
Row 2, Column 3
4
Row 3, Column 0
Row 3, Column 1
1x a day
2x a day
3x a day
As needed
1x a day
2x a day
3x a day
As needed
Row 3, Column 2
Oral
Sublingual
Topical
Subcutaneous Injections
Oral
Sublingual
Topical
Subcutaneous Injections
Row 3, Column 3
5
Row 4, Column 0
Row 4, Column 1
1x a day
2x a day
3x a day
As needed
1x a day
2x a day
3x a day
As needed
Row 4, Column 2
Oral
Sublingual
Topical
Subcutaneous Injections
Oral
Sublingual
Topical
Subcutaneous Injections
Row 4, Column 3
6
Row 5, Column 0
Row 5, Column 1
1x a day
2x a day
3x a day
As needed
1x a day
2x a day
3x a day
As needed
Row 5, Column 2
Oral
Sublingual
Topical
Subcutaneous Injections
Oral
Sublingual
Topical
Subcutaneous Injections
Row 5, Column 3
7
Row 6, Column 0
Row 6, Column 1
1x a day
2x a day
3x a day
As needed
1x a day
2x a day
3x a day
As needed
Row 6, Column 2
Oral
Sublingual
Topical
Subcutaneous Injections
Oral
Sublingual
Topical
Subcutaneous Injections
Row 6, Column 3
8
Row 7, Column 0
Row 7, Column 1
1x a day
2x a day
3x a day
As needed
1x a day
2x a day
3x a day
As needed
Row 7, Column 2
Oral
Sublingual
Topical
Subcutaneous Injections
Oral
Sublingual
Topical
Subcutaneous Injections
Row 7, Column 3
9
Row 8, Column 0
Row 8, Column 1
1x a day
2x a day
3x a day
As needed
1x a day
2x a day
3x a day
As needed
Row 8, Column 2
Oral
Sublingual
Topical
Subcutaneous Injections
Oral
Sublingual
Topical
Subcutaneous Injections
Row 8, Column 3
10
Row 9, Column 0
Row 9, Column 1
1x a day
2x a day
3x a day
As needed
1x a day
2x a day
3x a day
As needed
Row 9, Column 2
Oral
Sublingual
Topical
Subcutaneous Injections
Oral
Sublingual
Topical
Subcutaneous Injections
Row 9, Column 3
1
2
3
4
5
6
7
8
9
10
Name of Medication
Row 0, Column 0
Dosage
Row 0, Column 1
Frequency
1x a day
2x a day
3x a day
As needed
1x a day
2x a day
3x a day
As needed
Row 0, Column 2
Route of Administration
Oral
Sublingual
Topical
Subcutaneous Injections
Oral
Sublingual
Topical
Subcutaneous Injections
Row 0, Column 3
Name of Medication
Row 1, Column 0
Dosage
Row 1, Column 1
Frequency
1x a day
2x a day
3x a day
As needed
1x a day
2x a day
3x a day
As needed
Row 1, Column 2
Route of Administration
Oral
Sublingual
Topical
Subcutaneous Injections
Oral
Sublingual
Topical
Subcutaneous Injections
Row 1, Column 3
Name of Medication
Row 2, Column 0
Dosage
Row 2, Column 1
Frequency
1x a day
2x a day
3x a day
As needed
1x a day
2x a day
3x a day
As needed
Row 2, Column 2
Route of Administration
Oral
Sublingual
Topical
Subcutaneous Injections
Oral
Sublingual
Topical
Subcutaneous Injections
Row 2, Column 3
Name of Medication
Row 3, Column 0
Dosage
Row 3, Column 1
Frequency
1x a day
2x a day
3x a day
As needed
1x a day
2x a day
3x a day
As needed
Row 3, Column 2
Route of Administration
Oral
Sublingual
Topical
Subcutaneous Injections
Oral
Sublingual
Topical
Subcutaneous Injections
Row 3, Column 3
Name of Medication
Row 4, Column 0
Dosage
Row 4, Column 1
Frequency
1x a day
2x a day
3x a day
As needed
1x a day
2x a day
3x a day
As needed
Row 4, Column 2
Route of Administration
Oral
Sublingual
Topical
Subcutaneous Injections
Oral
Sublingual
Topical
Subcutaneous Injections
Row 4, Column 3
Name of Medication
Row 5, Column 0
Dosage
Row 5, Column 1
Frequency
1x a day
2x a day
3x a day
As needed
1x a day
2x a day
3x a day
As needed
Row 5, Column 2
Route of Administration
Oral
Sublingual
Topical
Subcutaneous Injections
Oral
Sublingual
Topical
Subcutaneous Injections
Row 5, Column 3
Name of Medication
Row 6, Column 0
Dosage
Row 6, Column 1
Frequency
1x a day
2x a day
3x a day
As needed
1x a day
2x a day
3x a day
As needed
Row 6, Column 2
Route of Administration
Oral
Sublingual
Topical
Subcutaneous Injections
Oral
Sublingual
Topical
Subcutaneous Injections
Row 6, Column 3
Name of Medication
Row 7, Column 0
Dosage
Row 7, Column 1
Frequency
1x a day
2x a day
3x a day
As needed
1x a day
2x a day
3x a day
As needed
Row 7, Column 2
Route of Administration
Oral
Sublingual
Topical
Subcutaneous Injections
Oral
Sublingual
Topical
Subcutaneous Injections
Row 7, Column 3
Name of Medication
Row 8, Column 0
Dosage
Row 8, Column 1
Frequency
1x a day
2x a day
3x a day
As needed
1x a day
2x a day
3x a day
As needed
Row 8, Column 2
Route of Administration
Oral
Sublingual
Topical
Subcutaneous Injections
Oral
Sublingual
Topical
Subcutaneous Injections
Row 8, Column 3
Name of Medication
Row 9, Column 0
Dosage
Row 9, Column 1
Frequency
1x a day
2x a day
3x a day
As needed
1x a day
2x a day
3x a day
As needed
Row 9, Column 2
Route of Administration
Oral
Sublingual
Topical
Subcutaneous Injections
Oral
Sublingual
Topical
Subcutaneous Injections
Row 9, Column 3
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23
Do you feel emotionally and physically safe at home/work?
*
This field is required.
Choose one
Yes
No
Sometimes
Choose one
Choose one
Yes
No
Sometimes
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24
Do you have worrying thoughts going through your mind a lot of the time?
*
This field is required.
Choose one
No
Yes
Sometimes
Choose one
Choose one
No
Yes
Sometimes
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25
Medical Records Release (optional)
I give authorization to the following individuals to review or receive my Protected Health Information (PHI). I understand that this authorization remains in effect until specifically rescinded by me in writing.
Name
Relationship
Name
Relationship
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26
Primary Insurance
This section may be skipped if uploading insurance cards at the end
Insurance Name
Member Identification #
Subscriber Name
DOB
Relation to Patient
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
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Chile
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Cote d'Ivoire
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Northern Mariana
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Secondary Insurance
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Insurance Name
Member Identification #
Subscriber Name
DOB
Relation to Patient
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United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
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Azerbaijan
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Bahrain
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Bosnia and Herzegovina
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Bulgaria
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Cameroon
Canada
Cape Verde
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Chile
China
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Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
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Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
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Eritrea
Estonia
Ethiopia
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Faroe Islands
Fiji
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France
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Chile
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28
Tertiary Insurance
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DOB
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United States
Afghanistan
Albania
Algeria
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Antigua and Barbuda
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Azerbaijan
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Bahrain
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Belarus
Belgium
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Bolivia
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Brazil
Brunei
Bulgaria
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Burundi
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Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
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Guinea
Guinea-Bissau
Guyana
Haiti
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Hong Kong
Hungary
Iceland
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Indonesia
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Italy
Jamaica
Japan
Jersey
Jordan
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Kenya
Kiribati
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Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
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Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
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Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
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Vanuatu
Vatican City
Venezuela
Vietnam
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Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
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Zimbabwe
Other
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
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Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
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Guadeloupe
Guam
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Guyana
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India
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Laos
Latvia
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Madagascar
Malawi
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Marshall Islands
Martinique
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Mayotte
Mexico
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Moldova
Monaco
Mongolia
Montenegro
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Morocco
Mozambique
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Nagorno-Karabakh
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Nauru
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Netherlands
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New Caledonia
New Zealand
Nicaragua
Niger
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Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
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Panama
Papua New Guinea
Paraguay
Peru
Philippines
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Poland
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Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
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Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
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