Patient Information Sheet
Patient Name
*
First Name
Last Name
Date Of Birth (Patient)
/
Day
/
Month
Year
Choose Data Of Birth
Social Security Number
*
Please enter your social security number
SEX
*
Male
Female
Transgender.
Prefer not to respond
Martial Status
*
Single
Married
Divorced
Widow
Separated
Address
*
Start Typing Address...
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Number (Cell)
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Number (Emergency)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Appt. Reminder Call Contact #
*
Home
Work
Cell
Other
Email
*
Enter Your Email Address
Primary Care Physician
*
Enter Your Primary Care Physician Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
*
Please enter a valid fax number.
Format: (000) 000-0000.
TRADITIONAL MEDICARE #
Enter Your Medicare
Primary Policy #
*
Start Typing Your Primary Policy
Identification Card/ Drivers License ( Front and Back)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Primary Health insurance Cards (Front and Back)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Secondary Health insurance Cards (Front and Back)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Don't have Documents Scanned?
I would provide in-person or through email.
PRIMARY INSURANCE
*
Straight Medicare
BCBS Medicare Advantage
BCN Medicare Advantage
Molina Medicare Advantage
Wellcare Medicare Advantage
Medicare & Medicare Advantage Plans
Other
Policy #
*
Start Typing Your Primary Policy
Group#
*
Start Typing Your Primary Policy
Effective Date
*
-
Day
-
Month
Year
Date
SECONDARY INSURANCE (If Applicable):
THIRD PARTY CONSENT:
* I understand and agree that, regardless of insurance status, I am responsible for the balance on this account for any professional services rendered. I certify the information provided is true and correct. I will notify Healthland HouseCall Services LLC of any changes in the above information, including insurance coverage, in a timely manner.
Initial:
*
Type Your Initial
PRIVACY PRACTICE:
I acknowledge that I have been provided access to Healthland HouseCall Services LLC Notice of Privacy Practices (NPP). I Acknowledge that I can obtain a copy of the full NPP from the front office. If I have any questions regarding the NPP, I will ask to speak with the privacy officer.
Initial:
*
Type Your Initial
AUTHORIZATION TO RELEASE INFORMATION:
I authorize Healthland House Call Services to communicate with my insurance company to coordinate treatment, to facilitate quality of treatment, and obtain reimbursement. By not signing consent, I am agreeing to full payment at the time of service.
Initial:
*
Type Your Initial
Patient Name
*
First Name
Last Name
Patient Signature:
*
Signature Date
*
-
Day
-
Month
Year
Date
Submit
Should be Empty: