Patient Info & Insurance

Patient Info & Insurance
PATIENT INFORMATION: THIS SECTION REFERS TO THE PATIENT ONLY
Name

First NameLast Name
Middle Initial
Date of Birth

MonthDayYear
Date
Social Security Number
Address
Apt, Lot, Unit
City
State
Zip
Sex

MaleFemale
Facility Name (if applicable)
Home Phone
Cell Phone
Race

American Indian or Alaska nativeAsianBlack or or African AmericanNative Hawaiian or Pacific IslanderWhiteUnknown/Decline to answer
Spouse's Name
Spouse's Date of Birth

MonthDayYear
Date
Spouse’s SSN
Do you have a dog?

YesNo
Would you like access to the patient portal?

YesNo
Email address for patient portal
example@example.com
How would you like appointment reminders?

CallTextBoth Call and Text
Cell number for reminder
Please enter a valid phone number.
RESPONSIBLE PARTY: THIS SECTION REFERS TO THE PERSON/PARTY WHO SHOULD RECEIVE THE BILL
Relationship to Patient

Self (skip to next section)SpouseOther
Name (of Responsible Party)

First NameInitialLast Name
Address (of Responsible Party)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone (of Responsible Party)
Cell Phone (of Responsible Party)
Work Phone (of Responsible Party)
INSURANCE INFORMATION
Primary Insurance Coverage
Effective Date (Primary Insurance)

MonthDayYear
Date
Address (of Primary Insurance)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Primary Insurance)
Policy Number (Primary Insurance)
Group Number (Primary Insurance)
Subscriber (Primary Insurance)
Subscriber’s DOB (Primary Insurance)
Subscriber’s SSN (Primary Insurance)
Secondary Insurance Coverage
Phone Number (Secondary Insurance)
Address

Address

Street Address Line 2

CityState

Zip
Policy Number (Secondary Insurance)
Group Number (Secondary Insurance)
Subscriber (Secondary Insurance)
Subscriber’s DOB (Secondary Insurance)
Subscriber’s SSN (Secondary Insurance)
OTHER INFORMATION
Pharmacy – Local
Address (Local Pharmacy)
Phone (Local Pharmacy)
Pharmacy – Mail Order
Address (Mail Order Pharmacy)
Phone (Mail Order Pharmacy)
Photo of Front of Insurance Card
Photo of Back of Insurance Card
Primary Care House Calls, 2744 Gulf Breeze Parkway, Gulf Breeze, FL 32563 Phone 850-934-5713 Fax 850-934-0379
Should be Empty:

Patient Info & Insurance

PATIENT INFORMATION: THIS SECTION REFERS TO THE PATIENT ONLY

RESPONSIBLE PARTY: THIS SECTION REFERS TO THE PERSON/PARTY WHO SHOULD RECEIVE THE BILL

INSURANCE INFORMATION

OTHER INFORMATION