Outpatient Form

Is this your legal name?

Yes No

If not, what is your legal name?

(Former name):

Birth Date:

Age:

Sex:

M F

Street Address:

Social Security Number:

Home Phone Number:

P.O. Box:

City:

State

Zipcode

Occupation:

Employer:

Employer Phone Number:

Chose Integrated Health Services/Referred to Integrated Health Services (please check one box):

Dr. Insurance Plan Hospital Family Friend Close to home/work Yellow Pages Other

Other family members seen here:

Insurance Information
(Please give your insurance card to the office manager.)
Person responsible for bill:	Birth Date:	Address (if different):	Home Phone Number:
Is this person a patient here? Yes No

Occupation:	Employer:	Employer Address:	Employer Phone Number:
Is this patient covered by insurance? Yes No
Please indicate primary insurance:

Subscriber’s name:	Subscriber’s S.S. no.:	Birth date:	Group no.:	Policy no.:	Co-payment:
Patient’s relationship to subscriber: Self Spouse Child Other Other

Name of secondary insurance (if applicable):	Subscriber’s Name:	Group no.:	Policy no.:
Patient’s relationship to subscriber: Self Spouse Child Other

In Case Of Emergency
Name:	Relationship to patient:	Home Phone Number:	Work Phone Number:
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize [Name of Practice] or insurance company to release any information required to process my claims. Patient/Guardian Signature Date

Today's Date:	PCP:
Reason for Referral:	Evaluation Requested Type of Evaluation:
Client Information
Adult Child
Patient’s last name: First: Middle:	Title: Mr Mrs Miss Ms	Marital status: Single Mar Div Sep Wid