Patient Information Sheet

Patient Information Sheet

5456 15 Mile Rd #101, Sterling Heights, MI 48310 | Phone: New Patients (586) 371-5590 Existing Patients (586) 666-2407
Dearborn, MI

5456 15 Mile Rd #101, Sterling Heights, MI 48310 | Phone: New Patients (586) 371-5590 Existing Patients (586) 666-2407

Sterling Heights, MI:

5456 15 Mile Rd #101, Sterling Heights, MI 48310 | New Patients
(586) 371-5590 | Existing Patients (586) 666-2407
Patient Name*

First NameLast Name
Date Of Birth (Patient)

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Social Security Number*
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SEX*

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Martial Status*

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Address*

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Phone Number*
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Phone Number (Cell)
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Phone Number (Emergency)*
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Appt. Reminder Call Contact #*

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Email*
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Primary Care Physician*
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Phone Number*
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Fax Number*
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TRADITIONAL MEDICARE #
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Primary Policy #*
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Identification Card/ Drivers License ( Front and Back)*

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Primary Health insurance Cards (Front and Back)*

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Secondary Health insurance Cards (Front and Back)*

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I would provide in-person or through email.
PRIMARY INSURANCE *

Straight MedicareBCBS Medicare AdvantageBCN Medicare AdvantageMolina Medicare AdvantageWellcare Medicare AdvantageMedicare & Medicare Advantage PlansOther
Policy #*
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Group#*
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Effective Date*

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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 Specialty Medical Center of any changes in the above information, including insurance coverage, in a timely manner.
Initial: *
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PRIVACY PRACTICE:

I acknowledge that I have been provided access to Specialty Medical Center 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: *
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AUTHORIZATION TO RELEASE INFORMATION:

I authorize Specialty Medical Center 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: *
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Patient Name*

First NameLast Name
Patient Signature:*

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Signature Date*

DayMonthYear
Date
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Patient Information Sheet

SECONDARY INSURANCE (If Applicable):

THIRD PARTY CONSENT:

PRIVACY PRACTICE:

AUTHORIZATION TO RELEASE INFORMATION: