Northeast Iowa Family Practice Center

NORTHEASTIOWAFAMILYPRACTICE CENTER

2055 KIMBALL AVENUE SUITE 101

WATERLOO, IOWA 50702-5047 (319)272-2112

**ADULT PATIENT INFORMATION (18 YEARS OF AGE AND OLDER)**

Today’s Date:______

How did you hear about us? Yellow pgs YP White pgs WP Newspaper NE Radio RATelevision TVWebsite WEB

Insurance Carrier INSFriend/Relative FR  Physician DRHospital HOSP Other OT Please Explain:______

Legal Name:(first, middle, last)______Male/Female

(Circle one)

Birth Date:(MM/DD/YYYY)______Marital Status:Single/Married/Separated/Divorced/Widowed

Maiden Name:(if applicable)______Social Security Number: ______

Ethnicity: Non-Hispanic/HispanicRace: ______Language preference: ______ (Circle one)

Home Address:______Apt/Lot #______

City/State/Zip:______

Phone Number: ( )______Alternate Number: ( ) ______

Your Email Address:______

Employer:______

May we contact you at work? YES NO If yes, Employer Phone No: ( )______(Circle one)

Employer’s Address:______

City/State/Zip:______

Spouse’s Legal Name:(first, middle, last)______

Spouse’s Birth Date:(MM/DD/YYYY)______Spouse’s Social Security Number:______

Spouse’s Maiden Name:(if applicable)______

Spouse’s Employer:______

May we contact spouse at work? YES NO If yes, Employer’s Phone No: ( )______(Circle one)

Spouse’s Employer’saddress:______

City/State/Zip:______

Person to contact in case of an Emergency, other than spouse:______

Phone Number: ( )______Relationship to you: ______

INSURANCE INFORMATION ON BACK

Primary Insurance Carrier: ______

Subscriber’s(Policy Holder) Legal Name:______

Subscriber’s Date of Birth:______Subscriber’s Social Security Number: ______

(MM/DD/YYYY)

Policy Number:______

Group Number:______Effective Date(MM/DD/YY):______Issued through employer? Yes  No

Subscriber’s Employer ______

Subscriber’s Address ______

Is this a family policy? Yes No If yes, who does it cover?______

Secondary Insurance Carrier: ______

Subscriber’s(Policy Holder) Legal Name:______

Subscriber’s Date of Birth: ______Subscriber’s Social Security Number ______

(MM/DD/YYYY)

Policy Number:______

Group Number:______Effective Date(MM/DD/YY):______Issued thru employer? Yes  No

Subscriber’s Employer ______

Subscriber’s Address ______

Is this a family policy? Yes No If yes, who does it cover?______

*****FILL OUT THE SECTION BELOW ONLY IF THE BILL IS TO BE SENT TO A DIFFERENT ADDRESS*****

Relationship: Father Mother Stepfather Stepmother GuardianOther

Name(first/middle/last):______

Address:______

City/State/Zip:______

May we contact the above named? Yes  No If yes, phone numbers: Home ( )______

Other ( )______

Assignment of Benefits/Release of Information

I, the undersigned assign directly to the Northeast Iowa Family Practice Center all medical benefits, if any, otherwise payable to me by my insurance company for services rendered. I understand that I am financially responsible for all charges whether paid or not by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions. My signature will be considered valid for a lifetime. This authorization applies to all services until the statement is revoked by me.

Signature of Insured/Guardian:______Date:______

Medicare/Medigap authorization

I request that payment of authorized Medicare/Medigap benefits be made on my behalf, to NortheastIowaFamilyPracticeCenter for any services furnished in their clinic. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable for related services. I also authorize any holder of medical information about me to release to my Medicare supplement any information needed to determine these benefits, or the benefits payable for related services. In Medicare Assignment cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as full charge, and patient responsible only for the deductible, coinsurance, and noncovered services. Coinsurance and deductible are based upon the charge determination of the Medicare carrier. My signature will be considered valid for a lifetime. This authorization applies to all services until the statement is revoked by me.

Beneficiary’s Signature:______Date:______