Patient Information

Date:

Age*:

Gender*:
Male / Female

Patient Name (as shown on insurance card)*:

Address*:

City*:

State*:

ZIP*:

Home Phone*:

Mobile:

Email:

Social Security Number*:

Date of Birth*:

Race:

Ethnicity:

Primary Language:

Employer/School:

Occupation:

Employer/School Address & Phone:

Marital Status*: Single Married Widowed Divorced

Primary Care Physician:

Other Medical Specialists (ie. Cardiologist, Neurologist):

Legal Guardian

Legal Name*:

Relationship*:

Social Security Number:

Date of Birth*:

Employer:

Employer Address & Phone:

Emergency Contact Other Than Spouse (Not in Same Household)

Legal Name*:

Relationship*:

Address*:

City*:

State*:

ZIP*:

Alternate Mailing Address:

Home Phone*:

Mobile:

Employer:

Employer Address & Phone:

Insurance Information

Insurance Company*:

Policy Holder's Name/Relationship*:

Social Security Number*:

DOB*:

Name as it appears on insurance card*:

Policy #*:

Group #*:


Secondary Insurance:

Policy Holder's Name/Relationship:

Social Security Number:

DOB:

Policy #:

Group #:

I authorize the release of any medical information necessary to process this claim.
I understand that services rendered today are my financial responsibility. Insurance is filed as a courtesy to you; there may be a difference between your benefits and fees.
I assign payment of medical benefits to J. Brian Sims, MD, PA, Brad Veazey, MD, PA, Toby Risko, MD, PA, Joshua North, MD, PA, Todd Bradshaw, MD, PA, and/or Reagan Crossnoe, MD, PA.

Signature*

Relationship (if not parent)