Maternal Fetal Medicine Associates-Valley Hospital Demographic Form at a glance
What it is: The Maternal Fetal Medicine Associates-Valley Hospital Demographic Form has patient information, emergency contact, responsible party, insurance information and referral info.
Who signs: Sign after Signature: and enter the Date.
A filled-in Maternal Fetal Medicine Associates-Valley Hospital Demographic Form example: a patient fills out the form
How to fill out Maternal Fetal Medicine Associates-Valley Hospital Demographic Form, box by box
Patient information
Under PATIENT INFORMATION, enter the Patient Last Name, First and Initial.
Enter the Street Address, City, State, Zip Code, Date of Birth and Age.
Enter the Social Security#, Home Phone #, Cell Phone #, Best Time to Call, Religion, Race, Occupation, Work # and Employer & Address, and mark the Marital Status: Single, Married, Divorced, Widowed or Separated.
Emergency contact
For the emergency contact, enter the Name, Relationship to Patient, Home Phone # and Cell Phone #.
Responsible party
For the responsible party, enter the Name, Relationship to Patient, Street Address, Phone #, City, State and Zipcode.
Primary insurance
Enter the Primary Insurance Company, Policy#, Group #, Claims Address and the Policy Holders Employer (if other than PT).
Enter the Patient's Relationship to Insured, the Policy Holders Name (if other than patient), the Subscriber's Social Security# and the Gender (Male or Female) and Date of Birth.
Secondary insurance
For the Secondary Insurance Company, enter the Policy#, Claims Address, Group #, Patient's Relationship to Insured, Policy Holders Name (if other than patient), Subscriber's Social Security # and the Gender (Male or Female) and Date of Birth.
Assignment and release, signed
Read the Assignment of Benefits and Release of Information and the Notice of Privacy Practices Acknowledgment, and sign.
By signing, you authorize your insurance benefits to be paid directly to Maternal Fetal Medicine Associates, PLLC and Valley Hospital, and you understand that you are financially responsible for all non-covered services.
You authorize the release of any medical or other information necessary to process insurance claims on your behalf.
Medicare Patients: you authorize any holder of medical or other information about you to release to the Centers of Medicare & Medicaid Services and its agents any information needed to determine benefits for this or a related Medicare claim, and you request that payment of authorized Medicare benefits be made either to you or the party who accepts assignment.
By signing, you acknowledge that you have been provided a copy of the Notice of Privacy Practices.
Sign after Signature: and enter the Date.
Sources
[1] Maternal Fetal Medicine Associates-Valley Hospital Demographic Form (4/2009), Valley Health System (the Official source link on this page).
