Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell Phone*Email* Date of Birth* MM slash DD slash YYYY Sex* Male Female Ethnicity Hispanic or Latino Not Hispanic or Latino Preferred Language Marital Status M W S D Drivers License # State Employed By/Retired Business Address Emergency Contact Not Living with you Relationship PhonePrimary Insurance Insurance Mailing Address ID# Group# Co-Pay Secondary Insurance Insurance Mailing Address ID# Referred by Primary DR. PhonePharmacy PhonePharmacy Location Reason For Today's Visit I understand I am financially responsible for all charges & copays whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I assign directly to your office all benefits and authorize the use of this signature on all insurance submissions, whether manual or electronic.Patient Signature* Date* MM slash DD slash YYYY
