NEIGHBORHOOD MEDICAL CENTER PATIENT INFORMATION SHEET
PATIENT NAME
Last name
First Name
Initial
Street Address
City
State
Zip Code
HOME PH
WORK PH
DOB
Sex
M F
Curent
Age
Patient. Social Security #
Emergency contact
Phone Number
Relationship to Patient
Employer
Wk Address
DO YOU HAVE MEDICAL INSURANCE
YESNO(If YES, continue)
Name Of Your PRIMARY Insurance Carrier
Policy Holder Name
ID #/SS# of insured
Relationship to insured
SelfChildSpouse
Policy #/Group#
IS THIS A WORKER'S COMPENSATION INJURY
YESNOIf YES, Date of Injury
Adjuster Name
Claim #
PH Number
PLEASE GIVE COPY OF OUR INDENTIFICATION AND YOUR INSURANCE CARD TO STAFF
PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED
NO MEDICARE/MEDICAID COVERAGE STATEMENT
I Certify that I am not currently enrolled under either medicare or Medicaid program and that I will not make a claim for program benefits under either of those programs for care and services that I may receive from NEIGHBORHOOD MEDICAL CENTER, ADDISON TEXAS.
