Patient Information Form

Personal Information
Maritial status:
Last Name
First Name
Initial
Birthdate SS# Sex
Street Address Apt# City
State Zip Home Phone
Cell # Work Phone
Email Address
Employer's Name
Employer's Address
Employers Phone Your Occupation
Spouse's Information
Last Name First Name Initial
Birthdate SS#
Patient's Insurance Information
 Self Pay (no Insurance) Yes No
Primary Insurance Company Name
Policyholder Name Policyholder birthdate
Relationship to Patient ID# Group #:
Secondary Insurance Company Name
Policyholder Name Birthdate
Relationship to PatientID#Group#
Patient's Referral Information
Primary Care Dr. / Referring Doctor
Address Phone
Pharmacy NamePharmacy Phone
Pharmacy Address
Emergency Contact
Name of person NOT living with you Relationship:
Street Address
Apt#
City
State
Zip Code
Home Phone
Work or Cell#

Should inaccurate or omitted insurance information be supplied causing a reduction or non-payment of benefits, the obligation of payment will be transferred to the responsible party. I hereby authorize the release of any medical information necessary for the processing of insurance. I hereby assign all medical and/or surgical benefits to include major medical benefits to which I am entitled to Digestive HealthCare Center. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment, or an electronic copy, is to be considered as valid as an original.

I Agree: