11 Updated Patient Information

Patient Information Update Packet

SFM Patient Information
Date*

MonthDayYear
Date
Patient Name*

First NameMiddle Name or InitialLast Name
Patient Date of Birth*

MonthDayYear
Date
Responsible Party (if not the Patient)

First NameMiddle Name or InitialLast Name
If Responsible Party, Relationship to Patient
Email*
example@example.com
Primary Phone Number*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Social Security Number*
ex. 123-45-6789
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

{patientName}		{patientDate}		{date}
Patient Name		Patient Date of Birth		Date Completed

Patient Age*
Sex*

MaleFemalePrefer not to answer
Marital Status*

SingleMarriedWindowedDivorced
Occupation
Employer
Emergency Contact*

First NameLast Name
Relationship to Patient*
Emergency Contact Phone Number*
Please enter a valid phone number.
Do you have insurance that Sparks Family Medicine accepts?*

YesI do not have insurance that Sparks Family Medicine accepts.

Primary Insurance Information

SFM Patient Information

{patientName}		{patientDate}		{date}
Patient Name		Patient Date of Birth		Date Completed

Please ensure that insurance information is accurate and up-to-date. Failure to provide accurate and current insurance information may result in the patient or responsible party being responsible for all charges. Please submit insurance cards and ID to SFM.
Primary Insurance*
Primary Plan Name*
Insured's Name for Primary Insurance*

First NameMiddle Name or InitialLast Name
Insured's Date of Birth for Primary Insurance*

MonthDayYear
Date
Insured's Gender for Primary Insurance*

MaleFemalePrefer not to answer
Insured's Social Security Number OR ID Number for Primary Insurance
Insured's Social Security Number OR ID Number for Primary Insurance*
Employer or Group Number for Primary Insurance
Employer or Group Number for Primary Insurance*
Primary Insurance Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's Relationship to Insured of Primary Insurance:*

SelfSpouseChildOther
Identify "Other:"*
Do you have Secondary insurance that Sparks Family Medicine accepts?*

YesI do not have a Secondary Insurance that Sparks Family Medicine accepts.

Secondary Insurance Information

SFM Patient Information
Please ensure that insurance information is accurate and up-to-date. Failure to provide accurate and current insurance information may result in the patient or responsible party being responsible for all charges. Please submit insurance cards and ID to SFM.

{patientName}		{patientDate}		{date}
Patient Name		Patient Date of Birth		Date Completed

Secondary Insurance (If none, type "Back" and select "No")*
Plan Name for Secondary Insurance*
Insured's Name for Secondary Insurance*

First NameMiddle Name or InitialLast Name
Insured's Date of Birth for Secondary Insurance*

MonthDayYear
Date
Insured's Gender for Primary Insurance*

MaleFemalePrefer not to answer
Insured's Social Security Number OR ID Number for Secondary Insurance*
Employer or Group Number for Secondary Insurance*
Secondary Insurance Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's Relationship to Insured of Secondary Insurance:*

SelfSpouseChildOther
Identify "Other:"*

Pharmacy Information

SFM Patient Information

{patientName}		{patientDate180}		{date57}
Patient Name		Patient Date of Birth		Date Completed

Local Pharmacy*
Please enter local pharmacy name or type "None"
Pharmacy Phone Number*
Please enter pharmacy phone number or write "None"
Pharmacy Street Address or Cross Streets*
Please enter pharmacy address or cross streets or write "None"
Mail Order Pharmacy
Please enter mail order pharmacy or write "None"
Mail Order Pharmacy Fax Number
Please enter a valid mail order pharmacy fax number
Mail Order Pharmacy Phone Number
Please enter a valid mail order pharmacy phone number
Medication Allergies and Reactions (if none, type "None"):

{patientName}		{patientDate180}		{date57}
Patient Name		Patient Date of Birth		Date Completed

Patient Consent to Bill

SFM Patient Information
I hereby authorized my insurance carrier to pay medical benefits directly to Sparks Family Medicine, Ltd. I authorize Sparks Family Medicine, Ltd. to release any medical information, including information related to psychiatric care, drug and alcohol abuse and HIV/AIDS confidential information, acquired in the course of my treatment necessary to process insurance claims or any medical information that is required for any health care related utilization review or quality assurance activities. I understand that I am financially responsible for all charges made to my account whether or not an insurance company is involved in payment. I am further responsible for all co-payment, co-insurance amounts, non-covered supplies and services, and yearly deductibles. I am also responsible for collection fees incurred by Sparks Family Medicine, Ltd. in efforts to receive payment of my financial obligations for services rendered. A photocopy of this authorization is to be considered as valid as the original, until revoked by me in writing.
HIPAA Authorization to Transmit PHI by Email*

Upload ID and Insurance Card(s). By uploading documents, patient or authorized representative authorizes Sparks Family Medicine and its third-party vendors to transmit uploaded documents as unsecure email attachments.I will fax ID and Insurance Card(s) to Sparks Family Medicine, Ltd at (702) 722-2201.
Upload ID and Insurance Card(s) *

Cancelof
Name of Person Signing this Form*

First NameMiddle Name or InitialLast Name
Date*

MonthDayYear
Date
Electronic Signature Acknowledgement and Consent*

I understand and agree that this electronic signature is the legal equivalent of my signature in writing and I consent to be legally bound to this agreement.
Authorization to Receive Password Protected Attachment*

I understand I will receive an email response at the provided email from Sparks Family Medicine, Ltd upon submission of this document with a PDF of the completed agreement attachment. I must use the password Patient#1 to open and save this attachment.
Signature*

Clear
Should be Empty:

Patient Information Update Packet

{patientName}

{patientDate}

{date}

Primary Insurance Information

{patientName}

{patientDate}

{date}

Please ensure that insurance information is accurate and up-to-date. Failure to provide accurate and current insurance information may result in the patient or responsible party being responsible for all charges. Please submit insurance cards and ID to SFM.

Secondary Insurance Information

Please ensure that insurance information is accurate and up-to-date. Failure to provide accurate and current insurance information may result in the patient or responsible party being responsible for all charges. Please submit insurance cards and ID to SFM.

{patientName}

{patientDate}

{date}

Pharmacy Information

{patientName}

{patientDate180}

{date57}

{patientName}

{patientDate180}

{date57}

Patient Consent to Bill