Pre-Admission
Please print out this form, fill it out, and bring
it with you when you come in for your scheduled appointment.
Confidential  Institute For Women's Health Dr.________________
| Acct: SSN: |
Phone: ( ) Cell: ( ) |
| Last Name: |
Date of Birth: / / Age: |
| First Name: |
Patient Employer: |
| Address 1: |
Occupation: |
| Address 2: |
Phone #: ( ) |
| City: |
 Single Married Divorced Widowed
|
| State: Zip: Country: |
Drivers License / ID#: |
| Spouse: |
Religion: |
| PCP:
Last
Name First
Name |
Email: |
| Phone #: ( ) |
|
|
| Primary Insurance: |
Secondary Insurance: |
| ID #: Group: |
ID #: Group: |
| Phone: ( ) Relation: |
Phone: ( ) Relation: |
| Relationship: Self
Spouse Child |
Relationship: Self
Spouse Child |
| Social Security #: DOB: |
Social Security #: DOB: |
| Employer Name: |
Employer Name: |
| Employer Telephone: ( ) |
Employer Telephone: ( ) |
|
| IN CASE OF AN EMERGENCY CONTACT: (Two relatives not living with you,
or friend in area).
| Name: |
Name: |
| Address: |
Address: |
| Phone: ( ) Relation: |
Phone: ( ) Relation: |
|
| PHARMACY INFORMATION:
| Name: |
Phone: ( ) |
| Address: |
E-Mail |
| Fax: ( ) |
|
|
| How did you hear about the Institute For Women’s Health?
Family
Friend
Co-worker Insurance
Radio
Internet
Healthfair
TV
Phonebook Primary Care Physician Other
Doctor or person who Refferred you:
______________________________
May we thank this person?
Yes No
|
| AGREEMENTS
OF BENEFITS:
I
HEREBY ASSIGN ALL MEDICAL AND/OR SURGICAL BENEFITS, TO INCLUDE
MAJOR MEDICAL BENEFITS TO WHICH I AM ENTITLED, INCLUDING
MEDICARE, PRIVATE INSURANCE AND ANY OTHER HEALTH PLANS,
TO INSTITUTE FOR WOMEN'S HEALTH. I UNDERSTAND THAT I AM
RESPONSIBLE FOR SCHEDULING WITH A PARTICIPATING PHYSICIAN
AND TO FOLLOW UP ON ANY DISCREPANCY IN COVERAGE WITH MY
INSURANCE PLAN. I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES
WHETHER OR NOT PAID BY MY INSURANCE. I HEREBY AUTHORIZE
INSTITUTE FOR WOMEN'S HEALTH TO RELEASE ALL INFORMATION
NECESSARY TO SECURE PAYMENT.
Signed: ____________________________________________________ Date: _____________________________
|
|
