IHC New Patient Enrollment Form

Health Information - Adult
I give my consent for Liberty Resources to access my immunization(s) and identifying information to and from the New York State Immunization Information System (NYSIIS).

YesNo
I give my consent for Liberty Resources to access my electronic protected health information (ePHI).

YesNo

Health Information - Children
I (the parent/guardian) give consent for Liberty Resources to access the child’s electronic protected health information (ePHI).

YesNo

Benefits and Payment Responsibility
PRIMARY INSURANCE INFORMATION
Name of Primary Insurance Company
Policy #
Subscriber's Name
Subscriber's DOB

MonthDayYear
Date
Subscriber's SS#
Subscriber's Employer
Subscriber's Relationship to the Patient
SECONDARY INSURANCE INFORMATION
Is the patient enrolled in a secondary insurance?

YesNo
Name of Secondary Insurance Company
Policy #
Subscriber's Name
Subscriber's DOB

MonthDayYear
Date
Subscriber's SS#
Subscriber's Employer
Subscriber's Relationship to Patient
Who is responsible for the bill?*

SelfOther
Name of the person responsible for the bill.

First NameLast Name
What is the responsible party's relationship to the patient (parent, guardian, etc)?
Is the responsible party's address the same as the patient, listed above?

YesNo
Responsible Party's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

New Patient Enrollment