Patient Information Sheet

Patient Information

Patient First Name:	Middle Name:	Last Name:
Permanent Address:	City:	State:	ZIP Code:
Mailing Address:	City:	State:	ZIP Code:
Home Phone:	Work Phone:	Cell Phone:	E-Mail:
Date of Birth:	Sex: Male Female
Marital Status Single Married Divorced Widowed
Patient Employment Information (if patient is a minor, parent complete)
Employee / Father's Place of Employment:	City, State:	Occupation:	Work Phone:
Employee / Mother's Place of Employment:	City, State:	Occupation:	Work Phone:
Who referred you to this office:
Nearest relative with different address:	Telephone:

Payment / Insurance Information

Private Pay Insurance - Please complete below

Primary Insurance Name:
Address:	City:	State:	ZIP Code:
Subscriber's Name:	ID:	Group ID:	Group Name:
Secondary Insurance Name:
Address:	City:	State:	ZIP Code:
Subscriber's Name:	ID:	Group ID:	Group Name:

Authorization

Name of person completing this form:

Relationship to Client:

Phone Number:

By submitting this form, you authorize the release of any medical or other information necessary to process these claims and also authorize payment of medical benefits to the provider for services described.

Please check if you do not want to receive information about new services, fundraising events or other BRSH news.