Transcription of Patient Information and Consent - Doctors Care
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Patient Information and Consent - Doctors Care
EMR DOCUMENT TYPE: Patient InformationPatient Forms Packet: Page 1 of 6, [PAT-F002-(08-14)] 2015 Doctors Care is a registered trademark of UCI Medical Affiliates, PrintPatient Information and ConsentPatient DemographicsEmergency Contact InformationPatient Employment InformationResponsible Party's Information (if someone other than Patient )Legal First NameLegal Last NameSuffixPreferred First NameWhat is the reason for your visit today?Have there been any changes to your Information in the past 6 months?NoYes(if no, please skip to the back page)Today's VisitNoYesHave you been treated at any Doctors Care office location before? Patient NamePermanent AddressApt. #CityZipStatePhone #Social Security #Birth DateGenderAlternate Phone #Local or Alternate AddressToday's DateContact NamePhone #Relationship to PatientName of a Relative not Residing With YouPhone #Employer NameEmployer Phone #Legal Name of Responsible PartySocial Security #AddressCityZipStateMedical Insurance InformationPolicy Holder's NamePolicy Holder's Social Security #Insurance CompanyPolicy Holder's Birth DatePolicy Holder's Relationship to PatientPolicy Holder's AddressPolicy Holder's EmployerCityZipStatePLEASE TURN THIS FORM OVER AND COMPLETE THE BACKA frican AmericanAmerican Indian/Alaska NativeAsianHispanicMixed RaceOtherRefuse to ReportWhiteHispanicNot HispanicRefuse to ReportRace:Ethnicity:LanguageMarital StatusEmail A
Patient health information (PHI) includes information about your symptoms, test results, diagnosis, treatment, and related medical information. Your patient health information (PHI) also includes payment, billing and insurance information. We are committed to protect the privacy of your PHI. How we use your patient health information (PHI)
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