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Please do not leave any blanks Patient Information Last Name: First Name: MI: Age: Has the patient been here before? Yes No Sex: Male Female SSN (###-###-####): Birth date (MM/DD/YYYY): Phone Numbers Home: Cell: Work: Address: City: State: AL AK AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA VI WA WV WI WY Zip Code: Email: Marital Status: Minor Single Married Divorced Widowed Separated Drivers License #: State: AL AK AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA VI WA WV WI WY Employer: Spouse's Information Name: Employer: Work Phone: Address: City: State: AL AK AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA VI WA WV WI WY Zip Code: Emergency Contact Name: Cell Phone: Work Phone: Name: Cell Phone: Work Phone: Insurance Information (Primary Cardholder) Name of Insured: Relationship to patient: SSN (###-###-####): Birth date (MM/DD/YYYY): Phone Numbers Home: Cell: Work: Address: City: State: AL AK AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA VI WA WV WI WY Zip Code: Employer: Responsible Party (If other than patient or patient is minor) Name: Relationship to patient: SSN (###-###-####): Birth date (MM/DD/YYYY): Phone Numbers Home: Cell: Work: Address: City: State: AL AK AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA VI WA WV WI WY 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: Date (MM/DD/YYYY):
Patient Information
Last Name: First Name: MI: Age:
SSN (###-###-####): Birth date (MM/DD/YYYY):
Phone Numbers
Address:
City: State: AL AK AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA VI WA WV WI WY Zip Code:
Email:
Marital Status: Minor Single Married Divorced Widowed Separated
Drivers License #: State: AL AK AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA VI WA WV WI WY Employer:
Spouse's Information
Emergency Contact
Name: Cell Phone: Work Phone:
Insurance Information (Primary Cardholder)
Name of Insured: Relationship to patient:
Employer:
Responsible Party (If other than patient or patient is minor)
Name: Relationship to patient:
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: Date (MM/DD/YYYY):
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