Transcription of Uptown Physicians Group 4144 North Central …
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Uptown Physicians Group 4144 North Central …
Uptown Physicians Group 4144 North Central Expressway, Suite 750. Dallas, TX 75204. (214) 303-1033 fax (214) 303-1032. Personal Information: Patient Name:_____. (Last) (First) (Middle). Address:_____Date:_____. City:_____ State:_____ Zip:_____ Sex: M / F. Home Phone:_____ Cell:_____ Other:_____. Social Security #:_____ Date of Birth:_____. Employer:_____ Phone:_____. Spouse/Partner:_____ Physician:_____. Emergency Contact:_____ Phone:_____. Reason for Visit:_____ Previous Doctor:_____. How did you hear about us?:_____ Pharmacy:_____. _____. Insurance Information: (for office use). Primary Insurance:_____ Policy Holder:_____. Group Number:_____ Policy Number:_____. Effective Date:_____ Office Copay:_____ Referral: Y/N. Benefits Payable at _____ After_____ Deductible_____Met?
Uptown Physicians Group Patient Consent Agreement Consent to the Use and Disclosure of Health Information for Treatment, Payment, or Healthcare Operations
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