Patient Information

Last name

First Name & Middle Initial

Street Address

City, State, Zip

Home Phone

Cell Phone

Work Phone

Sex

Male

Female

Non-Binary

Age

Date of Birth

SS#

Email

Preferred Pharmacy

In Case of Emergency, who do we contact? (Name & Phone #)

Patient Employer

Employer's Address

Person Responsible for Minor (Name & Phone #)

Insurance Information

Insurance

Yes

No

If yes, provide Insurance carrier (Provide copy to front desk)

Insured Party's Name

Insured Party's Date of Birth

Insured Party's SSN

Insured Party's Employer

Assignment & Release

I agree and understand by clicking "I AGREE" all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.

I have insurance coverage with the stated insurance provider above and assign directly to Cedar Creek Family Medicine all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of the signature on all my insurance submissions.

Please Select

I AGREE

Today's Date

Month

Day

Year

Medicare Authorization (if applicable)

I request that payment of authorized Medicare benefits be made either to me, or on my behalf, to Cedar Creek Family Medicine for any services furnished to me by that facility. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agent any information needed to determine these benefits or the benefits payable for related services. I understand that by clicking "I AGREE" Cedar Creek Family Medicine is authorized to the release of medical information necessary to pay the claim. If "other health insurance" is indicated in item 9 of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, that by clicking "I AGREE" Cedar Creek Family Medicine is authorized to the release of my information to the insurer or agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier.