Patient Demographics Form (Page 2 of 2) in pdf

City: _______________________ State: ____________ Zip Code: ______________

Name of Policy Holder: ___________________________ Date of Birth: ___________

Insurance ID Number: ________________________ Group Number: _____________

Secondary Insurance Company’s Name: _____________________________________

Insurance Address: (On the back of card.) ____________________________________

City: _______________________ State: ____________ Zip Code: ______________

Name of Policy Holder: ___________________________ Date of Birth: ___________

Insurance ID Number: ________________________ Group Number: _____________

Tertiary Insurance Company’s Name: ________________________________________

Insurance Address: (On the back of card.) ____________________________________

City: _______________________ State: ____________ Zip Code: ______________

Name of Policy Holder: ___________________________ Date of Birth: ___________

Insurance ID Number: ________________________ Group Number: _____________

Patient’s Referral Information

Primary Care Physician: _____________________________ Phone: ______________

Address: _________________ City: ________________ State: ______ Zip: ________

Referring Physician: ____________________________ Phone: __________________

Address: _________________ City: ________________ State: ______ Zip: ________

Please read and sign this form:

I hereby authorize my insurance benefits to be paid directly to Cardiac Wellness Specialists and Carolina

Sleep. I understand and am responsible for all charges including my added costs occurred due any effort to

collect for services rendered. I realize I am responsible to pay for all non-covered services and I hereby

authorize the release of pertinent medical information to insurance carriers.

Signature of Responsible Party: _____________________________ Date: __________

Patient Demographics Form Page 2