Family Medicine Patient Information Form

Dallas Family Medicine Patient Informatian

Patient Name: Age: Sex

Birthdate: Single: Married Widowed Divorced

Address: City: State: Zip:

Employer: Work Phone: Home Phone:

Cell Phone: Pager: e -mail:

Social Security: Occupation:

Emergency Contact: Emergency Phone: Confidential Information::

Parson responsible for payment: Relationship to patient: Employer:

Employer: Work Phone: Home Phone:

Social Security: Date of Birth:

Spouses Name: Work Phone: Employer:

Medical Insurance: Yes: No: 90 Day Prescription Plan:Yes: No: Have family member been here before: Yes: No:

Insurance Company : PCP: Referred by:

List any allergies: Your pharmacy: Pharmacy Phone:

I understand that it is my responsibility to provide this office with my current insurance information. Copays, deductibles and/or % are due and payable at the time of service. I understand that not all services may be covered by my insurance. I will be financially responsible for all non-covered services. Some services in this office are provided by a Certified Physician Assistant. ASSIGNMENT OF BENEFITS: I hereby assign all medical and/or surgical benefits, to include major medical benefits to which i am entitled, including Medicare, private insurance, and any other health plan to Paul S. Worell, D.O. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I hereby authorize said assignee to release all information necessary to secure payment for services rendered.