Patient Intake Form

Patient Intake Form
Patient Name*
Date of Birth*

MonthDayYear
Age
Social Security Number
Phone Number
Address
Marital Status

SingleMarriedWidowed/widowerDivorcedSeparated
Sex

MaleFemale
Employer
Occupation
Employer Address
Employer Phone
GUARANTOR(PERSON RESPONSIBLE FOR PAYMENT) OR RESPONSIBLE PARTY IF DIFFERENT FROM PATIENT
Guarantor Name
Guarantor Social Security Number
Guarantor Employer
Guarantor Occupation
Employer Phone
Employer Address
Insurance Information
Primary Insurance
Group #
Policy #
Policy Holder's Name
Address
Phone Number
Policy Holder Date of Birth

MonthDayYear
Policy Effective Date

MonthDayYear
Secondary Insurance
Group #
Policy #
Policy Holder's Name
Address
Phone Number
Policy Holder Date of Birth

MonthDayYear
Policy Effective Date

MonthDayYear
MEDICAID
Case Name
Program
Receipt Number
Case Number
Effective Date

MonthDayYear
INDUSTRIAL
Injured on the Job?

YesNo
Date of Injury

MonthDayYear
Employer
Claim Number
ACCIDENT
Was an automobile involved?

YesNo
Date of Accident

MonthDayYear
Location of Accident
Are you working now?

YesNo
Employer
Date of last day worked

MonthDayYear
Who referred you?
Address
Phone Number
Name of Family Doctor
Address
Phone Number
Last Doctor Seen
Address
Phone Number
PATIENTS THAT CARRY HEALTH INSURANCE SHOULD REMEMBER THAT PROFESSIONAL SERVICES ARE RENDERED AND CHARGED TO THE PATIENT AND NOT THE INSURANCE COMPANY. EVEN THOUGH AN INSURANCE CLAIM IS FILED, YOU WILL RECEIVE A STATEMENT EACH OMNTH IF YOUR ACCOUNT HAS A BALANCE DUE. THIS OFFICE CANNOT ACCEPT RESPONSIBILITY FOR COLLECTING YOUR INSURANCE CLAIM OR NEGOTIATING A SETTLEMENT ON A DISTPUTED CLAIM. YOU ARE RESPONSIBLE FOR PAYMENT OF YOUR ACCOUNT WITHIN THE LIMITS OF OUR CREDIT POLICY.

I CERTIFY THAT THE INFORMATION ON THIS FORM PROVIDED BY ME IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
Signature of Patient (or parent, if child is under 18 years)*

Clear
Date

MonthDayYear
INSURANCE AUTHORIZATION AND ASSIGNMENT (PLEASE READ AND SIGN)

I HEREBY AUTHORIZE STARK MEDICAL SPECIALTIES, INC. TO FURNISH INFORMATION TO THE INSURANCE CARRIERS CONCERNING MY ILLNESS AND TREATMENT AND HEREBY ASSIGN TO THE PHYSICIAN(S) ALL PAYMENTS FOR MEDICAL SERVICES RENDERED TO MYSELF OR MY DEPENDANTS.
Do you have a Living Will?

YesNo
Do you have a Durable Power of Attorney for Healthcare?

YesNo
If no, would you like us to provide you with Living Will forms?

YesNo
If no, would you like us to provide you with Durable Power of Attorney forms?

YesNo
Signature

Clear
Date

MonthDayYear
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Patient Intake Form

Insurance Information