Patient Demographic Information and Financial Release
Patient Information
* = required fields
First Name
*
MI
Last Name
*
Preferred Name (if different)
Account No.
Date of Birth
Marital Status
Married
Single
Divorced
Widowed
Street Address
Apt.
City
State
Zip
Address Type
Home
Relative
Other
Please Describe
Home Phone
Cell Phone
Work Phone
Preferred Contact
Home Phone
Cell Phone
Work Phone
Email Address
Social Security No.
Language
English
Spanish
Other
Enter Language
Race
American Indian/Alaska Native
Asian
Black or African-American
Native Hawaiian
White
Refused to report/unreported
Ethnicity
Hispanic or Latino
Non-Hispanic or Latino
Refused to report/unreported
Employed by
How did you hear about us?
Insurance Information
Do you have healthcare insurance?
Yes
No
Primary
Insurance Company
Please attach a scan or photo of the front of your insurance card
Please attach a scan or photo of the back of your insurance card
ID Number
Group Number
Subscriber Name
Date of Birth
Social Security No.
Relationship to Patient
Employer Name
Do you have secondary insurance?
Yes
No
Secondary
Insurance Company
Please attach a scan or photo of the front of your insurance card
Please attach a scan or photo of the back of your insurance card
ID Number
Group Number
Subscriber Name
Date of Birth
Social Security No.
Relationship to Patient
Employer Name
Emergency Contact Information
Name
Phone
Relationship
I hereby authorize the release of any medical and billing information necessary to process payment for claims and request benefits to be mailed directly to the physician until I revoke said authorization in writing. I understand that I (and spouse if married, or parent if minor) assume responsibility for payments of amounts due for services rendered and above the amount covered by insurance or the total amount, if I do not have applicable insurance coverage. My signature below guarantees my assumption of responsibility to the amount owed pursuant to this agreement.
Patient Signature
– Draw your signature below using a tablet, mouse or smartphone.
By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature(s).
Date
Authorization for Release of Information
Northland Women’s Health Care, P.C.
is authorized to release protected health information about the below named patient in the following manner and to identified persons.
First Name
*
MI
Last Name
*
Date of Birth
Account No.
Preferred Contact Phone
May we leave a voice mail for you that includes sensitive information?
Yes
No
May we discuss your information with others such as a Spouse or Parent?
*
Yes
No
Name
Relationship
Phone
Financial
Medical
Name
Relationship
Phone
Financial
Medical
Name
Relationship
Phone
Financial
Medical
May we send you information via text message?
*
Yes
No
When I mark YES,
I understand that if information is not sent in an encrypted manner there is a risk it could be accessed inappropriately, and I still elect to receive text communications.
Please select applicable box(es)
Appointment Reminder
Other
May we send you information via email?
*
Yes
No
When I mark YES,
I understand that if information is not sent in an encrypted manner there is a risk it could be accessed inappropriately, and I still elect to receive email communications.
Please enter email address
and select applicable box(es) below
Financial
Medical
Appointment Reminder
Breach Notification
Patient Rights
I have the right to revoke this authorization at any time.
I may inspect or copy the protected health information to be disclosed as described in this document.
Revocation is not effective in cases where the information has already been disclosed but will be effective going forward.
Information used or disclosed as a result of this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.
I have the right to refuse to sign this authorization and my treatment will not be conditioned on signing.
This authorization will remain in effect until revoked by the patient in writing.
Patient or Personal Representative Signature
– Draw your signature below using a tablet, mouse or smartphone.
By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Description of Personal Representative’s Authority
Date