Transcription of NEW PATIENT PACKET
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NEW PATIENT PACKET
NEW PATIENT PACKET PATIENT s Name: _____ Last Middle First Address: _____ City: _____ State: _____ Zip: _____ Home Phone: _____ Cell Phone: _____ Primary Contact: Home Phone Cell Phone Email Address: _____ Driver s License #: _____ DOB: _____ Gender: Male Female Social Security #: _____ Employer: _____ Work Phone: _____ Race: White Hispanic Black or African American Asian Decline to Report Other: _____ Ethnicity: Hispanic or Latino/a Not Hispanic or Latino/a Decline to Report Other: _____ Whom may we call in Case of Emergency? Name: _____ Relationship to PATIENT : _____ Primary Phone #: _____ PracticePolicy contractedwithtocollectcopayments, ,the ;however,itisyour signatureand$ refilled on the next business day.
PATIENT INTAKE FORM ... As a new patient, you will be asked to review and ... All payments are due at time of services rendered. Dr. Gruhlkey and providers of Lonestar Medical have a legal obligation to the insurance companies they are contracted with to collect copayments, deductibles, and coinsurance. ...
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