Patient Demographic Form

Patient Information, Health History, and Billing Information

Last Name:

First Name:

Middle Name:

Policy Holder Last Name:

Policy Holder First Name:

Policy Holder Middle Name:

Address:

City

State:

Zip +4:

Home Phone #:

Cell #:

Marital status:

Birth Sex:

Male

Female

Gender Identity:

Sexual Orientation:

Communication Preference

Email:

Preferred Language:

1* Pharmacy:

Address:

City:

State:

2* Pharmacy:

Address:

City:

State:

Previous Doctor:

Address:

Other Doctors & Specialty:

Race:

Ethnicity:

OTHER INFORMATION

Emergency Contact Name:

Relationship

Phone Number:

Employer Name:

Address:

City:

State:

Zip +4:

Work #:

Extension:

Occupation:

Spouse/Parent Employer's Name

Address:

City:

State:

Zip +4:

Work #:

Extension:

Occupation:

Work #:

MEDICAL INSURANCE INFORMATION

Primary Insurance Policy Holder Last Name:

First Name:

Middle Name:

Relationship to insured:

Other:

Name of Insurance Company:

Address:

City:

State:

Zip +4:

Insurance ID #:

Group ID:

Free Text

Secondary Insurance

Policy Holder Last Name:

First Name:

Middle Name:

Relationship to Insured:

Other:

Name of Insurance Comapny:

Address:

City:

State:

Zip +4:

Insurance ID #:

Group ID:

Free Text

PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

Free Text

With my consent, Mcgregor Medical may use and disclose protected health information (PHI) about me to carry out treatment, payment, and healthcare operations (TPO). Please refer to McGregor Medical Notice of Privacy Practices for a more complete description of such uses and disclosures.

Free Text

I have the right to review the Notice of Privacy Practices prior to signing this consent. McGregor Medical reserves the right to revise its Notice of Privacy Practices may be obtained by forwarding a written request.

Free Text

With my consent, McGregor Medical may call my home or other designated location and leave a message on voice mail or with appropriate individuals in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others.

Free Text

With my consent, McGregor Medical may e-mail or mail to my home or other designated location any items that the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential.

Free Text

I have the right to request that McGregor Medical restricts how it uses or discloses my PHI to carry out TPO. However, McGregor Medical is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

Free Text

By signing this form, I am consenting to McGregor Medical’s use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, McGregor Medical may decline to provide treatment to me.

Please Mark as Read

Read

Electronic Signature of Patient/LegalGuardian

Today's Date