Ins New Patient Form

NEW PATIENT FORM

Insurance
Patient's Name*

FirstMiddle (optional)Last
Address*

Street Address

CityState/Province

Postal/Zip Code
Primary Phone #*
Please add a valid phone number.
Secondary Phone #
Please add a valid phone number.
Work Phone #
Please add a valid phone number.
Email Address*
example@example.com
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemaleOther
Social Security # (Optional)
Marital Status*

SingleMarriedDivorcedWidowedOther
Occupation
Spouse's Name

FirstLast
Spouse's Date of Birth

MonthDayYear
Date
Primary Phone #*
Please add a valid phone number.
Secondary Phone #*
Please add a valid phone number.
Emergency Contact*

First NameLast Name
Relationship with Patient*
Phone #*
Please add a valid phone number.
Primary Care Physician*
Referring Physician*
Which racial category does the patient most closely identify with?*

African AmericanAsianWhiteHispanicNative AmericanNative HawaiianPacific IslanderOther
What is the patient's ethnicity?*

HispanicNot Hispanic
What is the patient's preferred language?*

EnglishSpanishOther
Insurance Information
Primary Insurance*
Policy #*
Group ID
Date of Birth*

MonthDayYear
Date
Name of the Policy Holder*

FirstLast
Insurance Card Photo (Front)
Insurance Card Photo (Back)
Employer
Employer Address

Street Address

CityState/Province

Postal/Zip Code
Work Phone #
Please insert a valid phone number.
Secondary Insurance
Policy #
Group ID
Name of the Policy Holder
Date of Birth

MonthDayYear
Date
I authorize TEXAS REGIONAL PHYSICIANS, its assignees and third-party collection agents to use the contact information I hove provided to communicate with me and to place calls to my home/cellular/employment telephone, leave voice or text messages and use pre-recorded/artificial/voice/text messages and/or auto- dialing devices in connection with any communication to me.Furthermore, I authorize Texas Regional Clinic to discuss my/ the patient's core with the following persons:*
Patient Signature*

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Today's Date

MonthDayYear
Date
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NEW PATIENT FORM

Insurance Information