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New Patient Information
First Name:
Last Name:
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Social Security:
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Sex:
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Date of Birth:
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Year:
Marital Status:
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minor
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Employer:
Occupation:
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Spouse or Parent's Name First:
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Whom may we thank for referring you to us?
Insurance Information
Billing Information
Name of person responsible for this account?
Social Security:
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Relationship to patient:
Phone:
Address:
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Zip:
Name of Employer:
Work Phone:
Primary Insurance
Name of Insured:
Relationship to patient
Date of Birth:
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Year:
Social Security:
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Date Effective:
Address:
City:
State:
Zip:
Insurance Company:
Insurance Claims Address:
City:
State:
Zip:
Provider Services Phone #:
Group #:
Employer #:
Secondary Insurance
Name of Insured:
Relationship to patient
Date of Birth:
January
February
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April
May
June
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October
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December
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Year:
Social Security:
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Date Effective:
Address:
City:
State:
Zip:
Insurance Company:
Insurance Claims Address:
City:
State:
Zip:
Provider Services Phone #:
Group #:
Employer #:
Symptoms
Reason for visit:
Legal Statements
All information submitted above will be treated and private and confidential. By clicking the submit button, you are authorizing the doctors and/or staff of Estill County Chiropratic to verify or authorize insurance benefits. In addition, you are also authorizing Estill County Chiropractic to contact you for the purpose of scheduling an appointment in our office. HIPPA requires that we have you read and sign the federally governed Health Care Privacy Notice. The Health Care Privacy Notice will explain when, where and why your confidential health information may be used, stored &/or shared and is a part of your permanent medical records which are maintained in this office. You may receive a free photocopy of this document that you have signed just by asking one of our staff. Estill County Chiropractic does not deny any benefits or service because of race, color, national origin, age, gender, disability, religious or political beliefs.
