psls_Patient_Information

Client Name
Date of Birth

MonthDayYear
Date
Address

Address

Street Address Line 2

CityState / Province

Zip
Parent/Guardian(s)
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Other
Format: (000) 000-0000.
Email
example@example.com
Alternate Contact(s)
Phone
Format: (000) 000-0000.
Primary Doctor
Phone
Format: (000) 000-0000.
Practice
Fax
Format: (000) 000-0000.
Primary Insurance Company
Provider/Precertification Phone #
Format: (000) 000-0000.
Subscriber or Policy #
Group #
Subscriber/Policy Holder Name
DOB

MonthDayYear
Date
Employer
Phone #
Format: (000) 000-0000.
Secondary Insurance Company
Provider/Precertification Phone #
Format: (000) 000-0000.
Subscriber or Policy #
Group #
Subscriber/Policy Holder Name
DOB

MonthDayYear
Date
Employer
Phone #
Format: (000) 000-0000.
If the patient accesses Medicaid, provide the Medicaid ID #
SEND IN COPIES OF YOUR INSURANCE CARD(S).

I understand and agree that regardless of my insurance status, I am ultimately responsible for this bill and for the balance of the account for any professional services rendered. I have read all information on this sheet and have completed the above answers. I certify this information is true and correct to the best of my knowledge. I will notify you immediately if there is any change in my status, in the above information, or in insurance coverage for the patient. I understand that any billed amount past due greater than 60 days from the date of invoice could be subject to collections and/or termination of services.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: