Inspire Santa Fe Medical Group's Medical In-Take Form

Your Information
Name (As It Appears on Your Insurance Card)*

First NameLast Name
Email*
example@example.com
Best Phone Number To Reach You*
Please enter a valid phone number.
Do You Have A Temperature?*

YesNo
What Is Your Temperature?*
Drug Allergies*

YesNo
Name of Drug and Reaction (i.e. hives, swelling)*
Date of Birth*

MonthDayYear
Marital Status?*
Your Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Care Provider Name:*
Other Physicians?*

Emergency Contact Information
Emergency Contact Name*
Emergency Contact Phone Number*
Please enter a valid phone number.
Relationship To Emergency Contact*
Insurance Information
Primary Insurance Name *
Insurance ID#*
Group Number*
Policy Holder's Name*

First NameLast Name
Secondary Insurance?*

YesNo
Secondary Insurance Information
Primary Insurance Name *
Insurance ID#*
Group Number*
Policy Holder's Name*

First NameLast Name
Pharmacy Benefit Company
Local Pharmacy and Location
Local Lab and Location
Local Imaging Facility

Assignment of Benefits
Financial Responsibility

All professional services rendered are charged to the patient and are due at the same time of service unless other arrangements have been made in advance with our business office. Necessary forms will be completed to file insurance carrier payments.

Assignment of Benefits

I hereby sign all medical and surgical benefits, including major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s), including Medicare, private insurance, and any other health/medical plan, to issue payment check(s) directly to Hillary E Norton MD PC, for medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance.

Authorization to Release Information

I hereby authorize Hillary E Norton MD PC to:
1. Release any information necessary to insurance carriers regardless of my illness and treatments;
2. Process insurance claims generated in the course of examination or treatment;
3. Allow a photocopy of my signature to be used to process insurance claims for the period of a lifetime.
This order will remain in effect until revoked by me in writing.

I have requested medical services from Hillary E Norton MD PC on behalf of myself and/or my dependents, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized.

I further understand that the fees are due and payable on the date that services are rendered, and agree to pay all such charges incurred in full immediately upon presentation of the appropriate statement. A photocopy of this assignment is to be considered as valid as the original.
Signature*

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Date*

MonthDayYear
Date
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Inspire Santa Fe Medical Group's Medical In-Take Form

Please Mark A Check If You Have Recently Experienced Any Of The Following Symptoms:

Your Information

Emergency Contact Information

Insurance Information

Secondary Insurance Information

Current Medications

Do You Have Or Have You Ever Had:

Surgeries and Dates

Family History

Social History

Vaccines

Assignment of Benefits