Cisca Pulmonary and Critical Care

Alexis A. Vazquez, D.O.

PATIENT DEMOGRAPHICS

Name (First, Middle, Last): ______

Date of Birth: ______Gender: M F Social Security Number: ______

Marital Status: S M D W Height: ______Weight: ______

Email: ______

Street Address: ______

City, State: ______Zip Code: ______

Home Phone: ______Cell Phone: ______

Work Phone: ______Other Phone: ______

Employer: ______

Emergency Contact Information

Contact Name: ______Relationship to Patient: ______

Phone Number(s): ______

Complete Address: ______

Physician Information

Primary Care Physician: ______Phone: ______Address: ______

Who referred you to our practice? ______

Phone: ______Address: ______

Insurance Information

PRIMARY Insurance Company: ______

Address: ______Phone: ______

Policy Number: ______Group Number: ______

Policy Holder: ______Relationship to Patient: ______

Policy Holder’s Date of Birth: ______

SECONDARY Insurance Company: ______

Address: ______Phone: ______

Policy Number: ______Group Number: ______

Policy Holder: ______Relationship to Patient: ______

Policy Holder’s Date of Birth: ______

I hereby authorize my insurance benefits to be paid directly to Cisca Pulmonary and Critical Care. I understand I am responsible for all charges, including costs incurred due to any effort to collect for services rendered. I realize I am responsible to pay for non-covered services and I hereby authorize the release of pertinent medical information required to file for medical benefits.

Signature of Responsible Party: ______Date: ______

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