I hereby authorize the physician and or any practitioner to release information to insurance carriers concerning my illness / treatment and permit
payment directly to the physician and or any practitioner at his / her election any benefits due for services rendered. I recognize and accept responsibility
for any charges incurred for my care.

Date

By clicking this box, I affirm that the information being submitted is accurate and true to the best of my knowledge. I am the patient, or I have the express permission of the patient to submit this personal / health care information.

	PATIENT INFORMATION

First Name	Last Name	Middle Initial
Marital Status	Social Security Number	Gender
Date of Birth
Address	City	State	Zip Code
Phone	Cell	eMail
RACE	ETHNICITY	PREFERRED LANGUAGE
COMMUNITY INFORMATION
Community Name	Phone Number	Room Number
Community Type
Community Address	City	State	Zip Code
EMERGENCY CONTACT
Emergency Contact	Relationship	Phone Number
MEDICAL POWER OF ATTOURNEY
First Name	Last Name	Relationship to Patient
PRIMARY INSURANCE INFORMATION
Plan Name If Medicare Replacement Plan, Please Select the Appropriate One Below: Upload Insurance / Drivers Liecnse	Member ID Group Number
SECONDARY INSURANCE INFORMATION
Plan Name	Member ID Group Number (if applicable)
GUARANTOR INFORMATION (Responsible for Balance Due)
First Name Last Name	Address City	State	Zip Code