PATIENT INFORMATION (PLEASE PRINT) Please …

George B. Blake, , PATIENT INFORMATION ( Please print ) Please read and complete the form in its entirety. Last Name: Date of Birth: First Name: MI: Sex: Marital Status: Address Line 1: E-mail: Address Line 2: Social Security: City: Employers Name: State: Zip: Work Number: Home#: Cell#: Primary Care Dr. Race: Language of choice: Referring Doctor: Ethnicity: Hispanic / Latino D Other: D Decline to report: D PHARMACY INFORMATION Pharm#2 Name:Preferred Pharma 's #1 Name: Location:Pharmac location: (Statements will be addressed to the responsible party) Responsible Party Name: Emergency Contact Name: Address: Address: Phone: Phone: Relationship: Relationship: INSURANCE INFORMATION PRIMARY INSURANCE: I PHONE# CLAIMS ADDRESS: GROUP#POLICY# BIRTH DATE: POLICY HOLDER NAME: SECONDARY INSURANCE: I PHONE# CLAIMS ADDRESS: GROUP#POLICY# BIRTHDATE:POLIC

Health System : Electronic Medical Records : Consent to Share My Health Information With the BayCare Electronic Health Exchange . The BayCare Electronic Health Exchange (BayCare eHX) is an exciting program designed to improve your health care

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