Patient Information

Patient's First Name*

Patient's Middle Name

Patient's Last Name*

Date*

e.g. mm/dd/yyyy

Patient's Address*

Street Address City State ZIP Code

Patient's Home/Cell Phone Number*

e.g. (555) 555-5555

Patient's Work Phone Number

e.g. (555) 555-5555

Patient's Email Address*

e.g. email@domain.com

Gender*

Male

Female

Marital Status*

Single

Married

Divorced

Widowed

Patient's Date of Birth*

Patient's Driver's License Number*

State of Patient's Driver's License*

Patient's Employer

Patient's Employer Phone Number

e.g. (555) 555-5555

Primary Health Insurance

Policyholder's Name

Policyholder's Date of Birth*

e.g. mm/dd/yyyy

Group Number

Policy Number

Contract Number

Secondary Health Insurance

Patient's Primary Care Doctor

Patient's Primary Care Doctor Phone Number

e.g. (555) 555-5555

Responsible Party Information

If you would like to add a different Responsible Party to your account information, please fill out the fields below. If there is no one to list here please skip this page and click "Next" at the bottom to proceed to the next step.

Responsible Party's Name

First Last

Responsible Party's Relationship to Patient

Responsible Party's Address

Street Address Address Line 2 City State ZIP Code

Responsible Party's Home Phone Number

e.g. (555) 555-5555

Responsible Party's Work Phone Number

e.g. (555) 555-5555

Responsible Party's Date of Birth

e.g. mm/dd/yyyy

Responsible Party's Driver’s License Number

State of Responsible Party's Driver’s License

Responsible Party's Employer

Responsible Party's Employer Phone Number

e.g. (555) 555-5555

Emergency Contact

Emergency Contact's Name

First Last

Emergency Contact's Phone Number

e.g. (555) 555-5555

Emergency Contact's Relationship to Patient

Authorizations, Agreements, and Acknowledgments

I authorize use of this form or a copy hereof on all my insurance submissions.

I authorize release of information to all my insurance carriers.

I authorize Tri-County Medical Clinic, PC to obtain insurance payments on my behalf and that such payment(s) be made directly to them.

I agree that I am responsible for my bill including payment for all services not covered by my insurance company.

I agree that if I do not pay for today's services, paperwork and/or prescriptions may be withheld until payment is received.

I agree that deductibles and co-insurance will be paid at the time of service.

I agree that if my insurance carrier requires a referral for today's visit and it is not obtained, I am responsible for payment in full for today's visit and any subsequent follow up care.

I acknowledge that all of the information and statements hereon are correct and true to the best of my knowledge.

By providing my mobile number and clicking Submit, I consent to receive recurring automated marketing and professional text messages from Tri-County Medical Clinic at the number provided. Message frequency may vary and message & data rates may apply. Reply STOP to cancel or HELP for help. Consent is not a condition of purchase.

Patient Information

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