Family Information Record

Account Number: ______________________________________________________________________________________

Hospital Name: ________________________________________________________________________________________

  • Address: ___________________________________________________________________________________________

  • Phone Number: _____________________________________________________________________________________

Date: ________

Head of Household (responsible party): ___________________________________________________________________

  • Home Phone Number: _______________________________________________________________________________

  • Address: ___________________________________________________________________________________________

  • Occupation: ________________________________________________________________________________________

  • Employer: __________________________________________________________________________________________

  • Employer's Address: _________________________________________________________________________________

  • Work Phone Number: ________________________________________________________________________________

  • Spouse: ____________________________________________________________________________________________

  • Occupation: ____________________________________________________________________________________

  • Employer: ______________________________________________________________________________________

  • Address: _______________________________________________________________________________________

  • Phone Number: _________________________________________________________________________________

  • Parent or Nearest Relative: ____________________________________________________________________________

  • Relationship: ____________________________________________________________________________________

  • Address: ________________________________________________________________________________________

  • Phone Number: __________________________________________________________________________________

FAMILY MEMBER INFORMATION

Please complete for all family members, whether a current patient or not.

Head of Household (last name, first name, MI): _____________________________________________________________

  • Birthdate: __________________________________________________________________________________________

  • Sex: _______________________________________________________________________________________________

  • Social Security Number: ______________________________________________________________________________

  • Marital Status: ______________________________________________________________________________________

Spouse (last name, first name, MI): ________________________________________________________________________

  • Birthdate: __________________________________________________________________________________________

  • Sex: _______________________________________________________________________________________________

  • Social Security Number: ______________________________________________________________________________

  • Marital Status: ______________________________________________________________________________________

Dependent (last name, first name, MI): ____________________________________________________________________

  • Birthdate: __________________________________________________________________________________________

  • Sex: _______________________________________________________________________________________________

  • Social Security Number: ______________________________________________________________________________

  • Marital Status: ______________________________________________________________________________________

Dependent (last name, first name, MI): ____________________________________________________________________

  • Birthdate: __________________________________________________________________________________________

  • Sex: _______________________________________________________________________________________________

  • Social Security Number: ______________________________________________________________________________

  • Marital Status: ______________________________________________________________________________________

Dependent (last name, first name, MI): ____________________________________________________________________

  • Birthdate: __________________________________________________________________________________________

  • Sex: _______________________________________________________________________________________________

  • Social Security Number: ______________________________________________________________________________

  • Marital Status: ______________________________________________________________________________________

List 2 friends who would generally know how to get in contact with you.

Name: __________________________________________ Phone Number: _______________________________________

Name: __________________________________________ Phone Number: _______________________________________

SEND CLAIMS TO:

Primary Insurance Company: ____________________________________________________________________________

Insurance Mailing Address: ______________________________________________________________________________

  • Name of Cardholder: ________________________________________________________________________________

  • ID Number: ________________________________________________________________________________________

  • Group Number: _____________________________________________________________________________________

  • Family Members Covered Under This Policy: _____________________________________________________________

Secondary Insurance Company: __________________________________________________________________________

Insurance Mailing Address: ______________________________________________________________________________

  • Name of Cardholder: _________________________________________________________________________________

  • ID Number: _________________________________________________________________________________________

  • Group Number: ______________________________________________________________________________________

  • Family Members Covered Under This Policy: ______________________________________________________________

I request that payment of authorized general insurance benefits be made on my behalf to this facility for any service furnished to me by the physician/clinic. I authorize any holder of medical information about me to release to my insurance company and its agents any information needed to determine these benefits or the benefits payable for the related services. I permit a copy of this authorization to be used in place of the original. I authorize the release of medical records to other treating physicians.

____________________________________________

Patient's Signature (Parent, if patient is a minor)

____________________________________________

Date

We will file your primary insurance. However, you are responsible for filing your secondary insurance if it is not a PPO or an HMO with which our facility participates. Even though we file your insurance, after 30 days we hold you responsible for payment of the bill. If you are unable to pay the balance in full, please contact our business office for payment arrangements. Welfare, Medicare, PPO, and HMO patients must present a valid medical card each time you come to the clinic. Worker's Compensation patients: please identify yourselves at the desk.