Patient Information
PATIENT INFORMATION
Patient’s full name
Date
Marital status
Single
Married
Divorced
Widowed
Social Security No.
Drivers License No.
Date of Birth
Age
Street Address
City
State
Zip
Home Phone
Cell
Work
Email
Employer Name
Occupation
Employment Status
Full Time
Part Time
Not Employed
Self Employed
Retired
Active Duty
Full Time Student
Part Time Student
Race
American Indian/Alaska native
Asian
Black/African American
Hawaiian/Pacific Islander
White
Other Race
Decline
Ethnicity
Hispanic/Latino
Non-Hispanic/Latino
Decline
Preferred language if other than English
Preferred communications
Text
Email
Phone
Mail
In case of emergency whom should we contact?
Phone
Relationship to emergency contact
SPOUSE INFORMATION
Name
Social Security No.
Employer
Cell Phone
STUDENTS AND MINOR PATIENTS
Mother’s name
Mother’s address
Mother’s employer
Home Phone
Cell Phone
Father’s name
Father’s address
Father’s employer
Home Phone
Cell Phone
Student’s school name
School address
Permanent mailing address
City
State
Zip
MEDICAL INSURANCE
Do you have healthcare insurance?
Yes
No
Primary
Company
Insured (subscriber)
Insured’s relationship to patient
Insured’s Social Security No.
Insured’s date of birth
Certificate or ID number
Group or policy number
Effective date (date coverage began)
Claim mailing address
City
State
Zip
Do you have secondary insurance?
Yes
No
Secondary
Company
Insured (subscriber)
Insured’s relationship to patient
Insured’s Social Security No.
Insured’s date of birth
Certificate or ID number
Group or policy number
Effective date (date coverage began)
Claim mailing address
City
State
Zip
If you have the ability to scan and upload documents to your computer, please scan and upload the front and back of your insurance card and upload it to us thru this form. If you do not have the ability to do that you can also fax a copy of your insurance card (front and back) to 816-795-3484. Please write the patient’s name on the insurance card.
Upload picture of front and back of Insurance Card here
(command-click to select multiple image files)
ASSIGNMENT OF INSURANCE BENEFITS/AUTHORIZATION TO RELEASE INFORMATION
I hereby authorize Independence Women’s Clinic, Inc. to file insurance and assign benefits directly payable to Independence Women’s Clinic, Inc. I authorize Independence Women’s Clinic, Inc. to release any medical or incidental information that may be necessary for either medical care or processing for financial benefits. I understand insurance claims are filed as a courtesy. All balances (including balances for failure to obtain a referral) are my responsibility. Co-pays and co-insurances are due at the time of service. Failure to fulfill my financial obligation may result in my account being forwarded to an outside collection agency, which may result in additional fees and service charges. Delinquent accounts may be reported to the credit bureau. I also understand a fee will be charged for insufficient checks.
Patient Signature
(required) – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button I understand and agree that this is a legal representation of my signature.
Date
Responsible Party Signature
– Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button I understand and agree that this is a legal representation of my signature.
Date