Back to homepage MD APPROVED__________
SENTINEL HEALTH PARTNERS, P.A.
2006
PATIENT INFORMATION
LAST NAME FIRST MIDDLE DATE OF BIRTH SOCIAL SECURITY #
_________________________________________________________________________________________________
MAILING ADDRESS (For Receiving Mail) CITY STATE ZIP HOME PHONE #
_________________________________________________________________________________________________
MARITAL STATUS (CIRCLE) MARRIED/SINGLE SEX (CIRCLE) MALE / FEMALE
_________________________________________________________________________________________________
EMPLOYER/OCCUPATION WORK PHONE #
_________________________________________________________________________________________________
BUSINESS ADDRESS CITY STATE ZIP
_________________________________________________________________________________________________
RESPONSIBLE PARTY INFORMATION
LAST NAME FIRST MIDDLE DATE OF BIRTH SOCIAL SECURITY #
_________________________________________________________________________________________________
RELATIONSHIP TO PATIENT EMPLOYER BUSINESS PHONE #
_________________________________________________________________________________________________
BUSINESS ADDRESS CITY STATE ZIP
_________________________________________________________________________________________________
EMERGENCY CONTACT: NAME ____________________________________ PHONE ________________________
PCP: __________________________________ REFERRING PHYSICIAN: _____________________________
INSURANCE INFORMATION ( PLEASE PRESENT INSURANCE CARD AFTER COMPLETING UPDATE)
COPY OF INSURANCE CARD MUST BE ON BACK OF UPDATE FORM
PRIMARY INSURANCE
NAME OF INSURANCE CO.
_________________________________________________________________________________________________
NAME OF INSURED DATE OF BIRTH ID#
_________________________________________________________________________________________________
GROUP NAME & NUMBER EMPLOYER EFFECTIVE DATE
_________________________________________________________________________________________________
SECONDARY INSURANCE (IF APPLICABLE)
NAME OF INSURANCE CO
_________________________________________________________________________________________________
NAME OF INSURED DATE OF BIRTH ID#
_________________________________________________________________________________________________
GROUP NAME & NUMBER EMPLOYER EFFECTIVE DATE
_________________________________________________________________________________________________
FINANCIAL POLICY
Payment of medical
fees is the responsibility of the patient and is due at the time of service.
If we are filing your insurance, it is your responsibility to pay us any deductible,
co-insurance, or any balance not paid by your insurance company at the time of service.
AUTHORIZATION TO PAY BENEFITS TO PHYSICIAN:
I hereby authorize payment of medical benefits to Sentinel Health Partners, P.A. for
services rendered. I also authorize the release of
any medical information to process insurance claims. I
acknowledge the responsibility to pay any debt incurred during my treatment.
SIGNED __________________________________________________________
DATE ___________________________
(IF PATIENT IS A MINOR, RESPONSIBLE PARTY MUST SIGN)
NOTIFICATION OF PATIENT PRIVACY POLICY:
Dear Patient, The Health Insurance Portability and Accountability Act (HIPAA) has mandated
that all health care providers
make available The Notice of Privacy Practices. This
Notice is posted in our waiting room for your review. Upon
request, a copy of The Privacy Notice will be made available to you. In signing below, you acknowledge that you understand a copy of this office’s
privacy statement will be available to you should you request it and is available for viewing in
this office’s waiting room. PLEASE READ THE
POSTED NOTICE OR REQUEST A COPY.
______________________________________
(Patient’s
Acknowledgement Signature)
_________________________(Date)
FOR OFFICE USE ONLY
UPDATED
BY ___________________________
DATE_____________________________