UPDATE YOUR PATIENT INFO

UPDATE YOUR PATIENT INFO
Patient Name
Age
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security #
Marital Status
Street Address
City
State
Zip Code
Home Phone
Format: (000) 000-0000.
Work Phone
Cell
What form of communication may we use to contact you?
Employer
Position
Email Address
example@example.com
Employer Phone
Format: (000) 000-0000.
Employer Address
Is the Patient a Minor?
If so, name of responsible party
Responsible party's Address
Phone
Format: (000) 000-0000.
Relationship to patient
Person(s) we may contact in case of an emergency:
Person 1 Name
Relationship to patient
Phone #1
Format: (000) 000-0000.
Phone #2
Format: (000) 000-0000.
Phone #1 Type
Phone #2 Type
Person 2 Name
Relationship to patient
Phone #1
Format: (000) 000-0000.
Phone #2
Format: (000) 000-0000.
Phone #1 Type
Phone #2 Type
Patient or Responsible Party Signature
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Who may we thank for referring you to us?
Medicare Eligible Patients
By Signing, I understand that Lang & Dr. Derek H. Lang have "opted out" of Medicare, effective November 1, 2004. I also understand that I will be responsible for payment of all charges incurred after the above date, including any laboratory work up (blood studies I further understand that these charges will not be sent to Medicare (no reimbursement) nor to my secondary insurance company (no reimbursement) because Medicare will not pay for any of my services.

I also agree to be responsible for all expenses incurred
Patient Name
Medicare #
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

UPDATE YOUR PATIENT INFO

Medicare Eligible Patients