Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell Phone*Email* Date of Birth* Date Format: MM slash DD slash YYYY Sex*MaleFemaleEthnicityHispanic or LatinoNot Hispanic or LatinoPreferred LanguageMarital StatusMWSDDrivers License #StateEmployed By/RetiredBusiness AddressEmergency Contact Not Living with youRelationshipPhonePrimary InsuranceInsurance Mailing AddressID#Group#Co-PaySecondary InsuranceInsurance Mailing AddressID#Referred byPrimary DR.PhonePharmacyPhonePharmacy LocationReason For Today's VisitI 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* Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.
