FORM #4 - PATIENT INFORMATION SHEET This notice describes how medical information about you may be used, disclosed, and how you can get access to this information. Step 1 of 4 0% Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Date of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*MobileEmail 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 ReactionsName of Facility/Apt Primary Caregiver Relationship Emergency contactName* First Last Relationship* Phone*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Power Of Attorney / Guarantor InformationDoes the Patient Have a POA/Guardian? Yes No Legal Status* POA Guardian Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*MobileFax Previous Healthcare ProvidersName First PhoneFax Name First PhoneFax Pharmacy Contact InformationPharmacy Name PhoneFax Primary InsurancePrimary 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 InsuranceSecondary 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 NumberPlease 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 nameDate* MM slash DD slash YYYY Time* : Hours Minutes AM PM CAPTCHANameThis field is for validation purposes and should be left unchanged.
