Advanced Technology...in the Office...in a Caring Environment
Patient Update Form
Patient update information, Authorization, and Consent Form.
Please have your insurance card with you when you come for your appointment.
Filling out this form will help speed your check-in process at your next appointment. Please fill in the form, print it, then bring it to your next appointment
Name (Last, First MI)
Work Phone (area code and number)
Home Phone (area code and number)
Cell Phone (area code and number
Should we contact you at your Home phone, Cell phone, or Work phone?
Social Security Number
May we leave a message on your answering machine or voice mail? Yes No
Address
City, State
Zip Code
Email Address
Marital Status: Married Single Divorced Widowed
Emergency Contact Relationship
Phone
Full Time Student Yes No Employed Full-time Part-time
Employer Phone
Occupation
Primary Care Physician Phone
Referring Physician
Pharmacy Name/Location Phone
Insurance Information
Primary Insured
Primary Insured Employer
Relationship to Patient
SSN Birth date (mm/dd/yy)
Address (if different from above)
City, State, Zip Code
Secondary Insured
Secondary Insured Employer
Relationship to Patient
Birth date (mm/dd/yy)
SSN
Address (if different from above)
City, State, Zip Code
Financial Responsibility, Authorization, and Consent
I authorize the assignment of insurance benefits to Advanced Women's Care and understand and acknowledge that I am responsible for payment of all items and services, regardless of insurance benefits, provided to me by Advanced Women's Care. This assignment will remain in effect until revoked in writing. A photocopy of this assignment is considered to be the same as the original. I acknowledge that my account must be kept current and any past due balances are due prior to my next visit. Failure to pay outstanding balances may result in the rescheduling of an appointment. Co-pays and deductibles will be collected at the time services are rendered.
I consent to the use and disclosure of my confidential health information for the purposes of treatment, payment, and/or practice operations. This consent will remain in effect until revoked in writing. The following information will be released unless stricken as a part of the medical record: sexual abuse information, child abuse and neglect information, AIDS/HIV, drug and alcohol abuse information, and psychiatric information.
Signature of Responsible Party_____________________________________ Date__________
Medicare authorization:
I request that payment of authorized Medicare benefit be made on my behalf to Advanced Women's Care. I authorize any holder of medical information about me to release the health care financing administration and its agents any information needed to determine these benefits or the benefits payable for related services. Understand my signature requests that payment be made and authorizes release of medical information necessary to pay decline. If other other health insurance is indicated in item 9 of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorized releasing of the information to the insurer or agency shown. In Medicare assign cases, a provider agrees to accept the charge determined of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and the deductibles are based on the charge determined by the Medicare carrier
Signature of Patient/Beneficiary__________________________________Date______________
Please complete the form, sign the appropriate line(s), and print the form. Please bring the form with you to your next appointment.