TGH Patient Information Form

TGH Patient Information Form

* Indicates a required field
Provider Name *
Name *

First Name Last Name
Patient DOB: *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Email *
example@example.com
Do you want to be notified of your benefits?

Yes No
Primary
Primary Insurance Company Name *
Primary Insurance Company Phone Number: *

- Area Code Phone Number
Primary Insurance Card I.D. # / Subscriber #: *
Primary Group #:
Primary Policyholder's Name: *

First Name Last Name
Primary Policy Holders DOB
Primary Client's Relationship: *

Self Spouse Child

Primary Policyholder's Mailing Address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Do you have a Secondary Insurance? *

Yes No
Secondary
Secondary Insurance Company Name:
Secondary Insurance Company Phone Number:

- Area Code Phone Number
Secondary Insurance Card I.D. # / Subscriber #:
Secondary Group #:
Secondary Policyholder's Name:

First Name Last Name
Secondary Client's Relationship:

Self Spouse Child

Secondary Policyholder's Mailing Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

I authorize the release of any confidential medical information necessary to process my medical claims and for the continuation of treatment to the insurance carriers as required by them. I understand that I am required to pay any health insurance deductible, co-insurance, or any other charges incurred which are not paid by my insurers or any third party payers. *

Yes
Should be Empty: