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(915) 300-2276
2204 Jeo Battle Blvd, suite D203 El Paso, Texas 79938
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Patient's Form - Heritage HealthCare Clinic Mansfield TX
PATIENT'S INFORMATION
Suffix
Mr.
Ms.
Mrs.
Dr.
Last Name
Middle Name
First Name
Gender
Male
Female
Marital Status
Single
Married
Seperated
Divorced
Widowed
SSN
Date of Birth
Spouse Name
HOME ADDRESS
APT#
CITY
STATE
Zip
HOME#
CELL#
WORK#
Email
EMPLOYER
CITY
STATE
Zip
EMERGENCY CONTACT PERSON(S)
CONTACT#
PREFERRED COMMUNICATION:
Home #
Cell #
Work #
Email
Mail
Decline
Other
GUARANTOR INFORMATION(Person Responsible for Payment of Bill)
Name
Relationship
Dob
SSN
HOME ADDRESS
APT#
CITY
STATE
Zip
EMPLOYER
CITY
STATE
Zip
Occupation
CELL#
WORK#
Email
INSURANCE INFORMATION
PRIMARY INSURANCE
INSURED NAME:
INSURANCE CO.:
POLICY #:
GROUP NAME:
SECONDARY INSURANCE
INSURED NAME:
INSURANCE CO.:
POLICY #:
GROUP NAME:
*IF THE PERSON INSURED IS DIFFERENT FROM THE GUARANTOR, PLEASE PROVIDE THE INFORMATION BELOW SO WE CAN ASSIST YOU IN FILING YOUR MEDICAL CLAIM.
Name
RelationShip
Dob
SSN#
EMPLOYER
CITY
STATE
Zip
HOME ADDRESS
APT#
CITY
STATE
Zip
Occupation
CELL#
WORK#
Email
I HEREBY AUTHORIZE YOU TO RELEASE ANY INFORMATION ACQUIRED IN MY EXAMINATION OR TREATMENT NECESSARY TO PROCESS MY INSURANCE CLAIMS. I RELEASE YOU FROM ALL LEGAL RESPONSIBILITY THAT MAY ARISE FROM THE ACT I HAVE AUTHORIZED.
I DO NOT AUTHORIZEYOU TO RELEASE ANY INFORMATION ACQUIRED IN MY EXAMINATION OR TREATMENT NECESSARY TO PROCESS MY INSURANCE CLAIMS. IN DOING SO I AM RESPONSIBLE FOR MY MEDICAL BILLS.
You must choose one check box!
Signature of Patient/Legally Authorized Representative
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