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Patient Demographics Form – Fill Out and Use

The Patient Demographics Form is used to collect information about your patients. This form may be required by law for some types of care and can be very important in protecting you from malpractice suits.

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Demographic Form Template Details

The Patient Demographics Form is a required document for any clinic or hospital. It contains information about the patient, such as name, date of birth, and insurance carrier. This form helps to ensure that clinics and hospitals are providing appropriate care for their patients. The Patient Demographics Form is also used to track patients' medical history. It's important to fill out this form accurately and completely to ensure that the patient receives the best possible care.

Here is the information relating to the PDF you were looking for to fill out. It can tell you the time you will require to finish patient demographics form, what parts you need to fill in and some additional specific facts.

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	sample church demographic form, printable patient demographics sheet, demographic form hospital, patient demographic form pdf

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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

Patient Demographics Form – Fill Out and Use

Demographic Form Template Details

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