Patient Demographics Form – Fill Out and Use This PDF

A Patient Demographics Form is a crucial document used by medical facilities to gather comprehensive information about a patient, including personal, insurance, and emergency contact details. This form facilitates the effective communication of a patient's background, ensuring tailored and efficient healthcare services. To streamline your upcoming medical appointments and ensure accurate medical support, please take a moment to fill out the Patient Demographics Form by clicking the button below.

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Patient Demographics Form PDF Details

The Patient Demographics Form utilized by Maternal Fetal Medicine Associates-Valley Hospital is a comprehensive document that gathers essential information from patients to facilitate healthcare provision and administrative processes. This form captures a wide range of patient data including personal identification details such as name, contact information—including home and cell phone numbers—and address, alongside demographic information like date of birth, age, social security number, and even details regarding patient's religion, race, marital status, and occupation. Crucially, it solicits information about the patient's primary and secondary insurance providers, policy numbers, and the policy holder's details, which are pivotal for billing and insurance claims purposes. It also seeks information regarding emergency contacts, indicating the importance of having someone to reach out to in case of urgent situations. Furthermore, patients are required to sign consents within the form, authorizing the direct payment of insurance benefits to the healthcare provider and the release of medical information necessary for the processing of insurance claims. This includes a clear directive for the handling of Medicare benefits, ensuring that patients understand their financial responsibilities for services not covered by insurance. Additionally, the form includes a section where patients acknowledge receiving a Notice of Privacy Practices, ensuring they are aware of their rights and the privacy policies in place to protect their personal and medical information.

Question	Answer
Form Name	Patient Demographics Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	ccf demographic e forms 2 hour online orientation, demographic form template, printable patient demographics sheet, basic demographic form 2019

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MATERNAL FETAL MEDICINE ASSOCIATES-VALLEY HOSPITAL

DEMOGRAPHIC FORM

PATIENT LAST NAME

FIRST

INITIAL

	INFORMATION
	INFORMATION	STREET ADDRESS
		STREET ADDRESS

		CITY			STATE	ZIP CODE		DATE OF BIRTH	AGE

		SOCIAL SECURITY#		HOME PHONE #			CELL PHONE #
							BEST TIME TO CALL:
	PATIENT	RELIGION:	RACE:		MARITAL STATUS: __ SINGLE __ MARRIED __ DIVORCED
	PATIENT					__ WIDOWED __ SEPARATED
						__ WIDOWED __ SEPARATED
		OCCUPATION:		WORK #		EMPLOYER & ADDRESS:

EMERGENCY CONTACT		NAME:				RELATIONSHIP TO PATIENT

		HOME PHONE #				CELL PHONE #
		HOME PHONE #				CELL PHONE #

RESPONSIBLE		NAME:				RELATIONSHIP TO PATIENT
	PARTY
	PARTY	STREET ADDRESS				PHONE #
		STREET ADDRESS				PHONE #

		CITY	STATE	ZIPCODE

		PRIMARY INSURANCE COMPANY				POLICY#		GROUP #

	INFORMATION	CLAIMS ADDRESS:				POLICY HOLDERS EMPLOYER (IF OTHER THAN PT)

		PATIENT'S RELATIONSHIP TO INSURED				POLICY HOLDERS NAME( IF OTHER THAN PATIENT)
		PATIENT'S RELATIONSHIP TO INSURED				POLICY HOLDERS NAME( IF OTHER THAN PATIENT)

		SUBSCRIBER'S SOCIAL SECURITY#				GENDER: ____ MALE ____ FEMALE
						DATE OF BIRTH:
		SECONDARY INSURANCE COMPANY				POLICY#
	INSURANCE
	INSURANCE	CLAIMS ADDRESS:				DATE OF BIRTH:
		CLAIMS ADDRESS:				GROUP #
		PATIENT'S RELATIONSHIP TO INSURED				POLICY HOLDERS NAME( IF OTHER THAN PATIENT)

		SUBSCRIBER'S SOCIAL SECURITY #				GENDER: ____ MALE ____FEMALE

REFERRAL	INFO	REFERRING PHYSICIAN'S NAME				ADDRESS:
		REFERRING PHYSICIAN'S NAME				ADDRESS:

		PHONE #

	RELEASE	Please read the following and sign below:
	RELEASE	Assignment of Benefits and Release of Information:
		Assignment of Benefits and Release of Information:
		I hereby authorize my insurance benefits to be paid directly to Maternal Fetal Medicine Associates, PLLC and Valley
		Hospital. I understand that I am financially responsible for all non-covered services. I authorize the release of
		any medical or other information necessary to process insurance claims on my behalf.
	&	Medicare Patients:
	&	I authorize any holder of medical or other information about me to release to the Centers of Medicare & Medicaid
	ASSIGNMENT
	ASSIGNMENT	Signature:				Date:
		Services and its agents any information needed to determine benefits for this or a related Medicare claim. I request
		that payment of authorized Medicare benefits be made either to me or the party who accepts assignment.
		Notice of Privacy Practices Acknowledgment
		By signing below, I acknowledge that I have been provided a copy of the Notice of Privacy Practices.

demographic form 4/2009

How to Edit Patient Demographics Form Online for Free

With the goal of allowing it to be as quick to apply as it can be, we developed our PDF editor. The whole process of preparing the demographic forms will be quick should you try out the following steps.

Step 1: The first thing should be to pick the orange "Get Form Now" button.

Step 2: Now, you are on the file editing page. You can add information, edit present information, highlight certain words or phrases, insert crosses or checks, add images, sign the form, erase unrequired fields, etc.

Feel free to provide the following details to complete the demographic forms PDF:

ccf demographic e forms 2 hour online orientation fields to fill out

The program will need you to prepare the STREET ADDRESS, PHONE, CITY, STATE, ZIPCODE, PRIMARY INSURANCE COMPANY, POLICY, GROUP, CLAIMS ADDRESS, POLICY HOLDERS EMPLOYER IF OTHER, PATIENTS RELATIONSHIP TO INSURED, POLICY HOLDERS NAME IF OTHER THAN, SUBSCRIBERS SOCIAL SECURITY, SECONDARY INSURANCE COMPANY, and GENDER MALE FEMALE DATE OF BIRTH part.

ccf demographic e forms 2 hour online orientation STREET ADDRESS, PHONE, CITY, STATE, ZIPCODE, PRIMARY INSURANCE COMPANY, POLICY, GROUP, CLAIMS ADDRESS, POLICY HOLDERS EMPLOYER IF OTHER, PATIENTS RELATIONSHIP TO INSURED, POLICY HOLDERS NAME IF OTHER THAN, SUBSCRIBERS SOCIAL SECURITY, SECONDARY INSURANCE COMPANY, and GENDER MALE FEMALE DATE OF BIRTH blanks to fill

In the Please read the following and sign, Signature, Date, E S A E L E R T N E M N G S S A, and demographic form area, point out the crucial data.

ccf demographic e forms 2 hour online orientation Please read the following and sign, Signature, Date, E S A E L E R T N E M N G S S A, and demographic form fields to fill

Step 3: As soon as you've selected the Done button, your document will be accessible for transfer to any type of gadget or email you specify.

Step 4: You can make copies of the document tokeep away from any kind of future concerns. You need not worry, we don't distribute or watch your information.

Patient Demographics Form – Fill Out and Use This PDF

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Patient Demographics Form – Fill Out and Use This PDF

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