Demographics – A Primary Care Clinic for Adults

Name

DOB:

Physical Address

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

May we leave a detailed message?

Email

May we discuss your healthcare via email?

Marital Status

Employment Status

Preferred Language

Race (Select all that apply)

Ethnicity

Hispanic or Latino
Not Hispanic or Latino
Not listed/Other
I prefer not to disclose

Insurance Company Name

Insurance ID & Group Number (alpha prefix if listed)

Guarantor Name (person responsible for billing/payment)

Phone number & Email of Guarantor

Emergency Contact Name & Phone Number

Relationship to Patient

I authorize A Primary Care Clinic for Adults (APCCFA) to release my medical information to my health insurance company in order to facilitate the processing of medical claims or prior authorization requests on my behalf.

Yes

fee the responsible

I understand that any tests performed outside of the office will be billed separately by another entity and these charges are my responsibility. This includes labs, imaging or services rendered by another provider/office. This is in addition to any charges from APCCFA.

Yes

I authorize treatment of the above named individual and agree to pay all fees for treatment. In the event that this account is referred to collections, I understand that I am responsible for any and all associated fees.

Yes

I authorize that my insurance benefits be paid directly to APCCFA. I understand that if my insurance benefits are not paid directly APCCFA, I am responsible for paying APCCFA the full amount due.

Yes

I understand I will be charged a $100 fee for any visits that I do not attend or do not provide 12 hours notice of cancelation.

Yes

I understand APCCFA will charge a $50 fee for any returned check and I am responsible for paying this fee, any fees charged to APCCFA by the bank and the original amount of the check.

Yes

E-Signature

Date