PATIENT INFORMATION

FREDERICKSBURG CHRISTIAN HEALTH CENTER
Date

MonthDayYear
Date
Name

First NameLast Name
Middle Initial
Date of Birth

MonthDayYear
Date
Age
Cell Phone Number
Please enter a valid phone number.
Sex

MaleFemale
Marital Status

SingleDivorcedMarriedSeperatedWidowed
Address

Mailing Address

Street Address Line 2

CityCountyState

Zip
Address

Physical Address

Street Address Line 2

CityCountyState

Zip
Employer
Occupation
Employers Address
Email Address
example@example.com
Patient's Spouse's Information Wife/Husband's Name:
Wife/Husbands Name
Cell Phone Number
Please enter a valid phone number.
Social Security Number
Spouses Employer Name
Email Address
example@example.com
Work Phone Number
IF YOU HAVE INSURANCE, PLEASE PROVIDE US WITH A COPY OF YOUR INSURANCE CARD.
Type of Insurance
Policy Holder Name
Relation to Patient
IF PATIENT IS UNDER THE AGE OF 18 OR LIVING WITH PARENTS please fill out the next 2 areas
Fathers Name
Address

Mailing Address

Street Address Line 2

CityCountyState

Zip
Fathers Employer
Mothers Name
Address

Mailing Address

Street Address Line 2

CityCountyState

Zip
Mothers Employer
EMERGENCY CONTACT NAME AND NUMBER
Pharmacy Name and Number that you use for medications
We ask that all patients pay for their office visit at the time of service, unless you have prior arrangements made with our billing department or payment plan agreement.

TO OUR PATIENTS WITH INSURANCE COVERAGE:

If you have a co-pay with your insurance, you must pay it at each office visit. We will be happy to file all charges with your insurance once you have given us your complete insurance information. We will ask to run a copy of your insurance card. Insurance information must be provided within 30 days of the appointment or the patient will be made a self-pay. However, if your insurance does not pay within 90 days, it is your responsibility to contact them in reference to payment. If you do not want us to file with your insurance, please let us know. Please contact our billing department for any assistance you may need. You will be reimbursed for any overpayment made to us or your insurance will be reimbursed for overpayments made by your insurance company.

WORKMAN'S COMPENSATION PATIENTS:

If you were injured in the course of employment, we will file your compensation claim for you once we have verification from your employer, the insurance carrier, and claim number. We will still ask for your personal insurance information for future use if needed. You will be responsible for any charges not pain within 90 days by your workman's compensation insurance. If at any time we can help you with your compensation claim, please contact our billing department.

Medicare requires all Medicare patients to sign the following before we can file your claim. I request that payment of authorized Medicare benefits be made either to me or on my behalf to Dr. Powell for any services furnished by that physician. I authorized any holder of medical information about me to release the Health Care Financing Administration and its agents, and to my insurance company, any information needed to determine these benefits or the benefits payable to related services.
Medicare ID
Signature of Medicare Patient

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Date

MonthDayYear
Date
ALL PATIENTS OR GUARANTOR PLEASE READ AND SIGN THE FOLLOWING:

I have read and understand all of the above. The information listed by me on the front is correct to the best of my knowledge. I am responsible for all bills not paid by insurance. I further agree in the event of nonpayment, to bear the cost of collection, and/or Court costs and reasonable legal fees should this be required. It is agreed that a photocopy serves at the original of this document. I have also read and understand all of the HIPPA rules designated on the Notice of Information Practices. If I do not want any of my PHI disclosed I agree to sign another form for that authorization.
Signature of patient

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Date

MonthDayYear
Date
INSURANCE AND COMPENSTATION PATIENTS PLEASE READ AND SIGN THE FOLLOWING:
I authorize the release of medical information to my insurance carrier(s) and authorized insurance payment directly to Fredericksburg Christian Health Center.
Signature of patient

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Date

MonthDayYear
Date
GUARANTOR FOR THIS PATIENT/ACCOUNT
Print Name
Signature

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Date

MonthDayYear
Date
Should be Empty:

FREDERICKSBURG CHRISTIAN HEALTH CENTER

INSURANCE AND COMPENSTATION PATIENTS PLEASE READ AND SIGN THE FOLLOWING: