FORM #4 – PATIENT INFORMATION SHEET | Temah Healthcare Services, LLC

Name*
Prefix First Middle Last
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Mobile
Email
Gender*
- Female
- Male
Marital Status*
- Single
- Married
Social Security Number*
Ethnicity
- Hispanic or Latino
- Black American
- White American
- Asian Americans
- Native American
- African
- European
Patient Diagnosis/ Health Issues:
Allergies and Reactions
Name of Facility/Apt
Primary Caregiver
Relationship
Emergency contact
Name*
First Last
Relationship*
Phone*
Address*
Street Address Address Line 2 City State ZIP Code

Power Of Attorney / Guarantor Information
Does the Patient Have a POA/Guardian?
- Yes
- No
Legal Status*
- POA
- Guardian
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Mobile
Fax

Previous Healthcare Providers
Name
First
Phone
Fax
Name
First
Phone
Fax
Pharmacy Contact Information
Pharmacy Name
Phone
Fax

Primary Insurance
Primary Carrier*
Medicare B*
- Yes
- No
Medicaid
- Yes
Subscriber Name*
Relationship to Patient*
Effective Date*
MM slash DD slash YYYY
Name of Employer
Company
Subscriber Social Security Number*
Subscriber D.O.B*
MM slash DD slash YYYY
Policy Number*
Group Number
Secondary Insurance
Secondary Carrier
Medicare B
- Yes
- No
Medicaid
- Yes
Subscriber Name*
Relationship to Patient*
Effective Date*
MM slash DD slash YYYY
Verification
Please enter
Subscriber Social Security Number*
Subscriber D.O.B*
MM slash DD slash YYYY
Policy Number*
Group Number
Please provide a photocopy of each side of your insurance card(s) – front and back and a photo identification card.
I certify that the information I have reported with regards to my insurance coverage is correct. I represent that I presently maintain insurance, which will reimburse the charges for THS and medical care being provided in consideration of THS providers. I hereby assign, transfer, and set over THS all of my rights, title, and interest to medical reimbursement benefits under my insurance policy(s) as indicated below by my signature. I certify that my address should be used for billing and correspondence purpose also.

I acknowledge that I have read and understand this form, that I have been given the opportunity to ask questions, and that I have no remaining questions at this time.
Name*
First Last
Relationship
Signature of Patient or Representative*

Enter full name
Date*
MM slash DD slash YYYY
Time*

: Hours

Minutes
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Name
This field is for validation purposes and should be left unchanged.

FORM #4 - PATIENT INFORMATION SHEET

Step 1 of 4

Emergency contact

Power Of Attorney / Guarantor Information

Previous Healthcare Providers

Pharmacy Contact Information

Primary Insurance

Secondary Insurance

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