Patient Demographics And Hipaa Form - Northern Arizona Allergy, Asthma, & Immunology

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NORTHERN ARIZONA ALLERGY, ASTHMA, & IMMUNOLOGY
PATIENT DEMOGRAPHICS AND HIPAA FORM
PATIENT INFORMATION:
LAST NAME: _______________________________
FIRST NAME: _________________________________
DOB: _______________________
AGE: ___________
PREFERED LANGUAGE: ______________
ETHNICITY: __________________________________
GENDER: M / F
MAILING ADDRESS: ________________________________________________________________________________________________________
CITY/ STATE/ ZIPCODE: _____________________________________________________________________________________________________
CELL PHONE NUMBER: _____________________________________
HOME PHONE NUMBER: ____________________________________
PREFFERED PHARMACY / PHONE NUMBER: _______________________________________ OCCUPATION: ________________________________
IF PATIENT IS A MINOR, PLEASE PROVIDE PARENTS/ GUARDIAN NAME: ______________________________________________________________
GUARANTOR INFORMATION/ RESPONSIBLE PARTY:
LAST NAME: _________________________________ FIRST NAME: __________________________________ DOB: ______________________
AGE: __________
SSN: ______________________ GENDER: M / F
MAILING ADDRESS: _______________________________________
CITY/ STATE/ ZIPCODE: _____________________________________
CELL PHONE NUMBER: __________________________________
HOME PHONE NUMBER: __________________________________________
INSURANCE INFORMATION:
PRIMARY INSURANCE: ____________________________________
POLICY NUMBER/ SUBSCRIBER I.D.: ___________________________
GROUP NUMBER: _______________
EFFECTIVE DATES: _______________
POLICY HOLDER DOB: _____________________________
ADDRESS: ______________________________________________
CITY/ STATE/ ZIPCODE: _____________________________________
INSURANCE PHONE NUMBER: ______________________________
PT RELATIONSHIP TO SUBSCRIBER: ____________________________
SECONDARY INSURANCE: _________________________________
POLICY NUMBER/ SUBSCRIBER I.D.: ____________________________
GROUP NUMBER: _______________
EFFECTIVE DATES: _______________
POLICY HOLDER DOB: ______________________________
ADDRESS: ______________________________________________
CITY/ STATE/ ZIPCODE: ______________________________________
INSURANCE PHONE NUMBER: ______________________________
PT RELATIONSHIP TO SUBSCRIBER: ____________________________
CONTACT INFORMATION:
** PLEASE PROVIDE A CONTACT NAME AND A DIRECT PHONE NUMBER OR A CONFIDENTIAL MESSAGE LINE IN ORDER FOR OUR OFFICE TO NOTIFY YOU /
THE PATIENT OF ANY RESULTS, APPOINTMENTS, BILLING INFORMATION, ETC. BY PROVIDING THIS CONTACT INFORMATION, YOU ARE GIVING OUR OFFICE
PERMISSION TO LEAVE MESSAGES REGARDING PRIVATE INFORMATION ABOUT YOU/ THE PATIENT.
CONFIDENTIAL PHONE NUMBER: _________________________________ MESSAGE LINE: ____________________________________________
IN ORDER TO RELEASE YOUR MEDICAL RECORDS TO ANOTHER PARTY, PLEASE FILL OUT THE “PATIENT DISCLOSURE FORM”.
OUR OFFICE WILL SUBMIT A CLAIM TO YOUR INSURANCE AS A COURTESY, HOWEVER, OFFICE VISITS, COPAYS, AND DEDUCTIBLES ARE
PAYABLE ON THE DATE OF SERVICE. INSURED PARTY WILL BE RESPONSIBLE FOR ALL FEES, REGARDLESS OF INSURANCE COVERAGE.
I HAVE READ THE ABOVE INFORMATION AND PROVIDED ALL CURRENT AND HONEST INFORMATION. I FULLY UNDERSTAND THIS
INFORMATION AND ALL OF MY QUESTIONS HAVE BEEN ANSWERED.
PATIENT/ LEGAL GUARDIAN SIGNATURE: _________________________________________________
DATE: ____________________________

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