St. Michael's ER - 24 hour Emergency Room

Houston Emergency Room
Now Open!

Please do not leave any blanks

Patient Information
Patient Name
Age
Has the patient been here before? Yes    No
Sex Male Female
SSN (last 4 digits only)
Birthdate (mm/dd/yyyy)
Home Phone
Cell Phone
Work Phone
Address (street, city, state, & zip code)

Email Address
Marital Status Minor         Single          Married
Divorced    Widowed    Separated
Driver's License #
State
Employer

Spouse's Information
Spouse's Name
Employer
Work Phone
Address (street, city, state, & zip code)

Emergency Contact
Name 1
Cell Phone 1
Work Phone 1
Name 2
Cell Phone 2
Work Phone 2

Insurance Information (Primary Cardholder)
Name of Insured
Relationship to Patient
SSN (last 4 digits only)
Birthdate (mm/dd/yyyy)
Home Phone
Cell Phone
Work Phone
Address (street, city, state, & zip code)

Employer
Policy #
Group #

Responsible Party (If other than patient or patient is minor)
Name
Relationship to Patient
SSN (last 4 digits only)
Birthdate (mm/dd/yyyy)
Home Phone
Cell Phone
Work Phone
Address (street, city, state, & zip code)

Employer

Consent for Treatment/Assignment of Benefits

I hereby voluntarily consent to medical care and routine diagnostic testing. I authorize the release of any medical information, records, reports, or copies thereof acquired in the course of my examination or treatment by St. Michael's Emergency Center and/or Sugar Land Emergency Physicians to process a claim. I authorize payment of medical/government benefits to the physician or supplier of services.

If the insurance companies denies responsibility, I understand that I will be billed for the balance. I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.

Signature
Today's date (mm/dd/yyyy)

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