Patient Demographic Information Form

Patient Demographic Information Form
Full Name*

First NameLast Name
Preferred Name
Middle Initial
Date of Birth*

MonthDayYear
Date
Social Security #
Sex at birth*

MaleFemale
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Other Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Primary Insurance Information

(skip this section if you do not have insurance)
Insurance Company Name
Insurance Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Policy/Member ID #
Policy Holder Name

First NameLast Name
Policy Holder Date of Birth

MonthDayYear
Date
Policy Holder Social Security #
Policy Holder Employer
Secondary Insurance Information

(Skip this section if you do not have secondary insurance)
Insurance Company Name
Insurance Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Policy/Member ID #
Policy Holder Name

First NameLast Name
Policy Holder Date of Birth

MonthDayYear
Date
Policy Holder Social Security #
Policy Holder Employer
Guardianship/Financially Responsible Party

Complete this section only if the patient is under 19, has a guardian, or is not the financially responsible party.
Who has legal authority to consent to this child’s medical care?

Both ParentsOne parentLegal guardianState/DHOther
Please specify which parent
Parent/Guardian Full Name

First NameLast Name
Parent/Guardian Date of Birth

MonthDayYear
Date
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship with the patient

ParentGuardianSpouseChildOther
2nd Parent/Guardian Full Name

First NameLast Name
2nd Parent/Guardian Date of Birth

MonthDayYear
Date
2nd Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
2nd Parent/Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2nd Relationship with the patient

ParentGuardianSpouseChildOther
Patient Data Information
Household income (Estimate annual total):
Number of family members in your household:
I do not wish to report my household size and/or income.
Are you a migrant farm worker?*

YesNoSeasonalChoose not to disclose
Do you need an interpreter?*

YesNo
Preferred language?
Are you a veteran?*

YesNoChoose not to disclose
Select which best describes your current housing*

Not HomelessDoubling up with Family/FriendsShelterStreetTransitionalUnknown/Choose not to disclose
Select your ethnicity. Select all that apply:

Not HispanicChicanoCubanMexicanMexican AmericanOther HispanicPuerto RicanUnknown/Choose not to disclose
Select your race. Select all that apply:*

American Indian or Native AlaskanAsian IndianBlack/African AmericanChineseFilipinoGuamanian/ChamorroJapaneseKoreanNative HawaiianOther AsianPacific IslanderSamoanVietnameseWhiteMore than one raceUnknown/Choose not to disclose
Emergency Contact / Release of Information
Emergency Contact Full Name

First NameLast Name
Relationship to patient
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Is this contact also approved to receive your (or the registered patient’s) healthcare information?

YesNo
Would you like any other individuals to receive healthcare information?

YesNo
Name

First NameLast Name
Relationship to patient
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name

First NameLast Name
Relationship to patient
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I authorize Heartland Health Center to disclose my health care information and to discuss my health care needs to those designated above. I understand that the individual(s) identified above will be treated by Heartland Health Center (HHC) as individuals involved directly in my (or the registered patient’s) care and as such will be allowed to release personal health information to these individuals for the purpose of treatment including making and cancelling appointments, consenting to individual patient care appointments (including vaccinations) or to any medical or dental treatment requiring written or informed consent, payment, or clinic operations.

I certify that the information provided is true and accurate to the best of my knowledge.
Patient/Guardian Signature:*
Date*

MonthDayYear
Date
Should be Empty:

Patient Demographic Information Form

Primary Insurance Information

Secondary Insurance Information

Guardianship/Financially Responsible Party

Patient Data Information

Emergency Contact / Release of Information