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PATIENT INFORMATION
Patient’s last name: First: Middle: ❏ Mr. ❏ Miss Marital Status (circle one)
❏ Mrs. ❏ Ms. Single / Mar / Div / Sep / Wid
❏ Dr. ❏ Insurance Plan ❏ Hospital ❏ Family ❏ Friend ❏ Close to home/work ❏ Yellow Pages ❏ Other
Email Address:
INSURANCE INFORMATION
Please indicate ❏ Workers ❏ Medicare ❏ Medicaid ❏ BCBS ❏ Humana ❏ United Health ❏ Aetna ❏ Cigna ❏ Other _______________
primary insurance: Compensation Care
IN CASE OF EMERGENCY
Name of local friend or relative (not living at same address): Relationship to patient: Home phone #: Work phone #:
ACKNOWLEDGEMENT OF NOTICE OF
(Initials) (Initials) PRIVACY PRACTICES
The above information is true to the best of my knowledge. The undersigned patient or legally authorized representative of
I authorize my insurance benefits be paid directly to the physician. the patient acknowledges that he or she was informed of the
I understand that I am financially responsible for any balance. I Center for Internal Medicine, Notice of Privacy Policies, as
also authorize Center for Internal Medicine or Insurance Company posted at the front desk, and available upon request, on the date
to release any information required to process my claims. below.