AALFA Patient Profile

AALFA
Legal Name LastFirstMI
Date of Birth

MonthDayYear
Date
Preferred Name
Sex
SSN
Marital Status
Preferred Phone
Alternate Phone
Address
CityState
Zip
Emergency Contact
Email
example@example.com
Primary Provider Provider Seen at AALFA
*We are required to ask for this information for state reporting. If you prefer not to provide this information please indicate below.
Race
White Black or African American Asian

American Indian or Alaskan Native
Preferred Language
Native Hawaiian/ Other Pacific Islander
Country in Which You Were Born
GUARANTOR*Person responsible for paying medical bills
Legal Name LastFirstMI
Date of Birth

MonthDayYear
Date
Address

Address

Street Address Line 2

CityStateState / Province

Postal / Zip Code
Zip
Primary Phone
Alternate Phone
SSN
PRIMARY INSURANCE
SECONDARY INSURANCE
Insurance Company
Insurance Company
Insured ID
Insured ID
Policy Group Number
Policy Group Number
Authorization to Release Information and to Pay Benefits to Physician: I hereby authorize AALFA FAMILY PRACTICE, P.A. to release any pertinent medical information acquired in the course of my exam and ongoing care to the above listed insurance carriers(s) and/or the physicians to whom I am referred. In addition, I also hereby authorize payment to be made directly to AALFA FAMILY PRACTICE, P.A.
Date

MonthDayYear
Date
Signature

Clear
Medicare Authorization: I request that payment of authorized Medicare benefits be made to me or on my behalf to AALFA FAMILY PRACTICE, P.A. for any services furnished me by that physician/clinic/supervisor I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. I permit a copy of this authorization to be used in place of the original.
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

AALFA

PRIMARY INSURANCE

SECONDARY INSURANCE