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New_patient_demographic_information_form

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					                               Patient Information Form           Page 1 / 2


Name: ______________________________________________ Date of Birth: ______________
      First   Middle Init Last

Address:
______________________________________________________________________________________

Sex: M F     Marital Status ___ Age ____ SS#______-_________-___________
Phone: Home _____________ Fax ____________ Cell ________________________

Email: _______________________ Best way to contact you: _____________________

Primary Caregiver: _______________________Relationship: ______________________


Emergency Contact: ____________________ Relationship: ______________________

Address:
_______________________________________________________________________
Home _______________ Fax ____________ Cell _________________________


Living Arrangements: Who lives with you?
______________________________________________________________

What sort of assistance do you have?
______________________________________________________________


Pharmacy:______________________ Phone _________________________
Fax_____________________


Primary Care Physician: ___________Phone ________________Fax________________

Address
_____________________________________________________________________
                                                                        page 2/2


Primary Insurance
Carrier:________________________________________________________________

SUBSCRIBER NAME___________________________ RELATION TO
PATIENT___________________

SUBSCRIBER SS# ____-___-________ SUBSCRIBER DATE OF BIRTH_______________

POLICY NUMBER:_____________________GROUP#________________________


MEDICARE IS MY: Primary insurance        Secondary insurance       Neither

Medicare #: ____________________ Effective Date Part B______________

Secondary Insurance
Carrier:_____________________________________________________________

SUBSCRIBER NAME________________________ RELATION TO PATIENT___________

SUBSCRIBER SS# ____-____-________ SUBSCRIBER DATE OF BIRTH_____________

POLICY NUMBER:________________________GROUP#________________________________


Please provide a photocopy of each side of your insurance card(s) – front and back.

I authorize the release of any medical or other information necessary to process my medical
claims.

SIGNED_________________________________________________________________
DATE____________________
Print Name______________________________________ Relationship __________________

I authorize payment of medical benefits to Fernow Medical House Calls and I acknowledge
that I am responsible for paying the fees associated with the services provided by Dr
Dr. Fernow and Fernow Medical House Calls if my insurance does not cover these services.

SIGNED__________________________________________________________________
DATE____________________
Print Name___________________________________________________________ Relationship




1047 South Street, Dover-Foxcroft, ME 04426       and     18 Country Rd, Westport, CT 06880
207-564-7131 Fax 207-433-5313                           203-204-1068 Fax 207-433-5313___

				
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