acehealthclinic.com - Patient Information Form

Patient Information
Patient Name

First NameMILast Name
DOB

MonthDayYear
Date
SSN#
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different)
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Preferred Method of Contact
Sex
Marital Status
Ethnicity
Race

Other
Preferred Language

Other
Local Pharmacy Name
Pharmacy Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Pharmacy Major Cross Streets
Pharmacy City
Do you have a mail order pharmacy?
If yes which one
Emergency Contact Name
Relation to Patient
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Carrier
Member ID #
Policy Holder Name
Policy Holder DOB

MonthDayYear
Date
Assignment Responsibility & Release
I hereby assign my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any non covered services and attorney or collection agency fees if it becomes necessary. I also authorize the physician to release any information required to process claim.
Do you have a living will?
Do you have a Medical Power of Attorney (POA)?
If yes, who is your Medical POA?
*****PLEASE PROVIDE A COPY OF THIS FOR YOUR IN-OFFICE FILE*****

Effective January 1, 2023, any established patient who fails to show or cancels/reschedules an appointment and has not contacted our office with at least 24 hours notice will be considered a No Show and charged a $25.00 fee. Any established patient who fails to show or cancels/reschedules an appointment with no 24 hour notice a second time will be charged a $50.00 fee. If a third No Show or cancellation/reschedule with no 24 hour notice should occur the patient may be dismissed from Ace Health and Wellness. Any new patient who fails to show for their initial visit will not be rescheduled. The fee is charged to the patient, not the insurance company, and is due at the time of the patient’s next office visit.
Patient Signature
Date

MonthDayYear
Date
Should be Empty:

Patient Information

Assignment Responsibility & Release