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 |
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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 |
MATERNAL FETAL MEDICINE
DEMOGRAPHIC FORM
PATIENT LAST NAME |
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INITIAL |
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INFORMATION |
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STREET ADDRESS |
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CITY |
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STATE |
ZIP CODE |
DATE OF BIRTH |
AGE |
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SOCIAL SECURITY# |
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HOME PHONE # |
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CELL PHONE # |
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BEST TIME TO CALL: |
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PATIENT |
RELIGION: |
RACE: |
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MARITAL STATUS: __ SINGLE __ MARRIED __ DIVORCED |
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__ WIDOWED __ SEPARATED |
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OCCUPATION: |
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WORK # |
EMPLOYER & ADDRESS: |
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EMERGENCY CONTACT |
NAME: |
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RELATIONSHIP TO PATIENT |
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HOME PHONE # |
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CELL PHONE # |
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RESPONSIBLE |
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NAME: |
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RELATIONSHIP TO PATIENT |
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PARTY |
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STREET ADDRESS |
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PHONE # |
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CITY |
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ZIPCODE |
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PRIMARY INSURANCE COMPANY |
POLICY# |
GROUP # |
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INFORMATION |
CLAIMS ADDRESS: |
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POLICY HOLDERS EMPLOYER (IF OTHER THAN PT) |
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PATIENT'S RELATIONSHIP TO INSURED |
POLICY HOLDERS NAME( IF OTHER THAN PATIENT) |
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SUBSCRIBER'S SOCIAL SECURITY# |
GENDER: ____ MALE ____ FEMALE |
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DATE OF BIRTH: |
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SECONDARY INSURANCE COMPANY |
POLICY# |
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INSURANCE |
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CLAIMS ADDRESS: |
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DATE OF BIRTH: |
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GROUP # |
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PATIENT'S RELATIONSHIP TO INSURED |
POLICY HOLDERS NAME( IF OTHER THAN PATIENT) |
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SUBSCRIBER'S SOCIAL SECURITY # |
GENDER: ____ MALE ____FEMALE |
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REFERRAL |
INFO |
REFERRING PHYSICIAN'S NAME |
ADDRESS: |
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PHONE # |
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RELEASE |
Please read the following and sign below: |
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Assignment of Benefits and Release of Information: |
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I hereby authorize my insurance benefits to be paid directly to Maternal Fetal Medicine Associates, PLLC and Valley |
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Hospital. I understand that I am financially responsible for all |
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any medical or other information necessary to process insurance claims on my behalf. |
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Medicare Patients: |
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I authorize any holder of medical or other information about me to release to the Centers of Medicare & Medicaid |
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ASSIGNMENT |
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Signature: |
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Date: |
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Services and its agents any information needed to determine benefits for this or a related Medicare claim. I request |
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that payment of authorized Medicare benefits be made either to me or the party who accepts assignment. |
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Notice of Privacy Practices Acknowledgment |
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By signing below, I acknowledge that I have been provided a copy of the Notice of Privacy Practices. |
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demographic form 4/2009