Patient InsuranceName *Date of Birth *Social Security *0 / 11Email Address *Mobile *Work PhoneStreet Address *Apartment, suite, etcCity *State *ZIP Code *Pharmacy *Gender *SelectMaleFemaleRelationship Status *SelectSingleMarriedDivorcedWidowedEmployment Status *SelectFull Time StudentUnemployedEmployedRetiredResponsible/Insured Party *SelectHusbandWifeDadMomOtherSame as Above (Move on to next section)GenderSelectMaleFemaleNameDate of BirthSocial Security0 / 11Email AddressMobileWork PhoneStreet AddressApartment, suite, etcCityStateZIP CodeName of Insurance Company *Name of Insured Person *Date of Birth *Social Security *0 / 11Employer Phone *Employer Name *Relationship to Patient *SelectHusbandWifeDadMomOtherInsurance Effective Date *Member ID Number *Group Number *Copay Amount *Name of Insurance CompanyName of Insured PersonDate of BirthSocial Security0 / 11Member ID Number *Group NumberCopay Amount1. Emergency/HIPPA Contact Name *Relationship to Patient *SelectHusbandWifeDadMomOtherContact Phone Number *2. Emergency/HIPPA Contact NameRelationship to PatientSelectHusbandWifeDadMomOtherContact Phone Number3. Emergency/HIPPA Contact NameRelationship to PatientSelectHusbandWifeDadMomOtherContact Phone NumberConsent *By filling out these insurance forms and submitting online, I hereby authorize my insurance benefits to be paid directly to Springtown Family Health Center (Dr. Gene McDaniel), realizing I am responsible to pay any and all non-covered services. I authorize the release of any pertinent medical information to insurance carriers and I hereby state that all information given on this form is correct and true. I also understand that Springtown Family Health Center files my insurance as a courtesy to me, and any incorrect or falsified information given will terminate such courtesy and payment will be due in full at the time of service. All payments are rendered at the time service unless arrangements have been made. Today's DateSend Message
