Get Health Information Patient Demographics Form

Filling out the Health Information Patient Demographics Form online is a straightforward process. This guide will provide you with step-by-step instructions to ensure that you complete the form accurately and efficiently.

Follow the steps to successfully complete your form.

1. Click ‘Get Form’ button to access the form and open it in your preferred online platform.
2. Begin with the Patient Information section. Enter your name in the format of last name, first name, and middle initial. Select your sex by circling the appropriate option (male or female).
3. Provide your home telephone number and your cell phone number. Indicate your marital status by circling married (M), single (S), or divorced (D). Enter your Social Security number and your birth date.
4. Fill in your complete address, including street, apartment number (if applicable), city, state, and zip code. Indicate your ethnicity, race, and primary language spoken.
5. In the Employer Information area, list the name and address of your employer. Specify your employment status by circling active, retired, or other, and provide your work telephone number.
6. For Referral Information, select how you heard about the provider by checking the appropriate box. Options include friend/family, primary care physician, insurance, internet, phone book, advertisement, or other.
7. Provide your email address. Move to the Communication Preference section and indicate whether you would like to receive reminders for health service appointments. Check how you prefer to receive such reminders.
8. Next, complete the Guarantor section if someone else is responsible for payment. Enter their name, relationship to you, address, social security number, date of birth, and employment details.
9. Fill out the Emergency Contact Information section with the name and relationship of the person you wish to designate as your emergency contact. Include their phone numbers.
10. In the Insurance section, provide details for both primary and secondary insurance, including the company name, policyholder's details, relationship to insured, and any relevant identification numbers.
11. Review the Financial and Treatment Consent and add your signature and date at the bottom of the section. Make sure you understand the consent terms before signing.
12. Finally, acknowledge receipt of the Notice of Privacy Practices by initialing where indicated. Ensure you have completed the entire form accurately.
13. Once you are satisfied with your entries, you can save changes, download, print, or share the completed form as necessary.

Take the first step towards your health management by filling out the form online today.