Crosspointe New PatientForm

Crosspointe New Patient Form
PATIENT INFORMATION
Name:

First NameLast Name
Patient ID#:
Sex:

MaleFemale
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:

MonthDayYear
Date
Social Security #:
Marital Status:

MarriedSingle
Home Phone:
Please enter a valid phone number.
Work Phone:
Please enter a valid phone number.
Cell Phone:
Please enter a valid phone number.
Email Address:
example@example.com
Primary Care Physician:
PATIENT EMPLOYMENT
EmployedRetiredNot Employed
Employer:
Phone:
Please enter a valid phone number.
EMERGENCY CONTACTS (NAME & PHONE)
1) Name:
Phone Number:
Please enter a valid phone number.
2) Name:
Phone Number:
Please enter a valid phone number.
3) Name:
Phone Number:
Please enter a valid phone number.
RESPONSIBLE PARTY

(Must complete if responsible party is other than the insured or patient.)
Same as PatientSame as Injured
Name:
Relation to Patient:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer:
Phone:
Please enter a valid phone number.
Social Security #:
Date of Birth:

MonthDayYear
Date
PRIMARY INSURANCE

(Must complete in its entirety in order for us to file with your insurance.)
Name of Insured:
Relation to Patient:
Name of Insurance Company:
Insured Policy Number
Insured SS#:
Policy Group #:
Insurance Phone #:
Please enter a valid phone number.
Insured Employer:
Insured Date of Birth:

MonthDayYear
Date
***IS THE PATIENT COVERED UNDER ANY OTHER INSURANCE?

YesNo
(IF YES, PLEASE COMPLETE SECONDARY INSURANCE BELOW.)
SECONDARY INSURANCE

(if applicable)
Name of Insured:
Relation to Patient:
Name of Insurance Company:
Insured SS#:
Policy Group #:
Insurance Phone #:
Please enter a valid phone number.
Insured Employer:
Insured Date of Birth:

MonthDayYear
Date
PHARMACY

(Please share the information of your preferred pharmacy)
Pharmacy Name
Pharmacy Phone Number
Please enter a valid phone number.
Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I understand that this form must be completed in its entirety. I understand that if all of the above information is not completed, a claim may not be able to be filed to my insurance company; therefore, making me fully responsible for any charges incurred.
How did you hear about us?

Family/FriendDoctorLocationYellow PagesInsuranceInternetOther
Patient/Responsibility Party Signature:

Clear
Should be Empty:

Crosspointe New Patient Form

PATIENT INFORMATION

PATIENT EMPLOYMENT

EMERGENCY CONTACTS (NAME & PHONE)

RESPONSIBLE PARTY

PRIMARY INSURANCE

SECONDARY INSURANCE

PHARMACY