850-926-­4200

Patient Information Form

* Indicates a required field

Provider Name*
Name:*
Date of Birth:*
Address:*
E-mail:*
Do you want to be notified of your benefits?
Social Security #:
Primary Insurance Company Name *
Primary Insurance Company Phone Number:*
-
Insurance Card I.D. # / Subscriber #:*
Group #:
Policyholder's Name:*
Policyholder's DOB:*
Client's Relationship:*
Policyholder's Mailing Address:*
Secondary Insurance Company Name:
Secondary Insurance Company Phone Number:
-
Secondary Insurance Card I.D. # / Subscriber #:
Secondary Group #:
Secondary Policyholder's Name:
Secondary Policyholder's DOB:
Secondary Policyholder's Mailing Address:
Secondary Client's Relationship:
I authorize the release of any confidential medical information necessary to process my medical claims and for the continuation of treatment to the insurance carriers as required by them. I understand that I am required to pay any health insurance deductible, co-insurance, or any other charges incurred which are not paid by my insurers or any third party payors.*