Patient Information Sheet printable pdf download

PATIENT INFORMATION

Patient’s SSN _____________________________

Male _______

Female _______

Email ___________________________________________________________

Patient’s Name _______________________________________________________________________________________________

(Last)

(First)

(Middle)

Patient’s Address _____________________________________________________________________________________________

(Street or P.O. Box)

(City)

(State)

(Zip Code)

Phone Numbers: Home ____________________

Work ____________________

Cell ____________________

Birth Date _______________ Age ______ Referring and/or Family Physician ___________________________________________

Race

: __________________ Ethnicity

Hispanic

Non-Hispanic Preferred Language: __________________

(Optional)

Patient’s Employer ____________________________________________________________________________________________

Employer’s Address ___________________________________________________________________________________________

Spouse’s Name ______________________ SSN ____________ Employer ________________________ Phone # ____________

Emergency Contact ___________________________________________ Relationship _______________ Phone # ______________

IF PATIENT IS A CHILD:

Mother _______________________ SSN ____________ Employer ___________________________ Phone # _______________

Father _______________________ SSN ____________ Employer ___________________________ Phone # _______________

Primary Insurance: ____________________ Group ____________________ Policy # ______________

Policy Holder Name ________________________ SSN _________________ *DOB ______________

Secondary Insurance: __________________ Group ____________________ Policy # ______________

Policy Holder Name ________________________ SSN _________________ *DOB ______________

*We must have the date of birth of the Insurance Policy Holder to file your insurance claims.

*** Please attach Insurance Card(s) and Driver’s License so we can make a copy for your records.***

Please Note:

Office visits, office surgeries, non-surgical treatments, and some hospital procedures are paid at the time of service unless you have a

contract insurance such as Medicare, BC/BS, Cigna, Blue Choice, etc. If you are using contract insurance, you will be required to pay

your co-payment and/or deductible at the time of service.

I understand that I am responsible for all charges until paid. I understand that I am responsible for obtaining prior authorization, all

deductibles, co-payments, and cost shares, including deductible and co-payments.

Authorization: I authorize Drs. Goulding, Ploch and Brisson of Palmetto Adult and Children’s Urology, PA to release medical

information to insurance carriers and medical professionals concerning my illness or treatments. I authorize payment of medical benefits

to the physicians of Palmetto Adult and Children’s Urology, PA for services rendered.

Patient’s Signature ______________________________________________________________ Date _______________________

(Parent or Guardian if patient is a minor)

Revised 3/2012

Patient Information Sheet

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