Patient Demographic Form - Advanced Heart and Vascular Institute

Name

Date

Last 4 digits SS#

Race/Ethnicity

Address

Phone Home

Phone Cell

Phone Work

Emergency Contact

Contact Name

Relationship

Emergency Contact 1

Emergency Contact 2

Pharmacy

Pharmacy Address

Primary Provider

Insurance Information

Name of Company

Policy #

Name of Insured

Group

Address of Company

Street Address City State / Province / Region ZIP / Postal Code

Relationship to patient

Copay amounts

Effective Date

Expiration Date

Permission is hereby granted to healthcare providers within this practice for testing, examinations, treatment, and procedures as deemed necessary, during the course of my care, including HIV testing in the event of body fluid exposure. Information necessary to substantiate my insurance claims may be released by this provider. I authorize payment directly to the provider’s office of all insurance benefits otherwise payable to me for services rendered. I understand I am financially responsible for all charges whether, or not paid by my insurance, for all services rendered on my behalf or on my dependents.

Signature of patient/guardian

Date

Comments

This field is for validation purposes and should be left unchanged.