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Creative Medical Communications, LLC
Patient Intake Form
Name
*
SS#
DOB
*
Gender
*
Male
Female
Marital Status
*
M
D
S
W
Address
City
State
Zip
Phone
Email
*
Physician Information
Referring Physician
*
Specialty
City
Phone number
Fax number
Insurance information
Primary Insurance
*
Policy Holder
*
DOB
*
Address
City
State
Zip
Phone
*
Relationship to patient
Policy/Member #
*
Group
Insurance phone
Secondary Insurance
Policy Holder
DOB
Address
City
State
Zip
Phone
Relationship to patient
Policy/Member #
*
Group
Insurance phone
Emergency Contacts
Name
*
Relationship to Patient
*
Cell Phone
*
Accept all terms and conditions
Terms & Conditions
For and in consideration of the services rendered by CREATIVE MEDICAL COMMUNICATIONS, I agree to pay said provider of services for all services needed. I understand that I am responsible for all health insurance deductibles, co-payments and coinsurance charges not covered by my insurance policy to include but not limited to charges for service, experimental investigation and/or not medically necessary as determined by my insurance company. In consideration of services rendered, I hereby transfer and assign CREATIVE MEDICAL COMMUNICATIONS all rights, title, and interest in any payments due to me for services described herein as provided in the above-mentioned policies of insurance or settlements or judgments. I hereby consent to the release of information necessary to process claims with my insurance company. I understand that the person giving authorization may revoke this authorization by a written and dated notice except to the extent that disclosure of information that has been made prior to the receipt of the revocation. I have read and understand this consent and I have signed it voluntarily and of my own free will.
Signature of Patient/Representative (Electronically Signed)
*
Date
*
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