Get Patient Demographics Form

Completing the Patient Demographics Form online is a straightforward process that ensures your essential information is accurately captured. This guide will provide you with clear, step-by-step instructions tailored to help you successfully fill out each section of the form.

Follow the steps to accurately complete the form

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Begin by entering your personal information. Fill in your Social Security Number, last name, first name, and middle initial in the corresponding fields.
3. Indicate the responsible party's name if applicable. Then, provide your date of birth in the MM/DD/YYYY format and select your sex from the available options.
4. State your marital status by selecting from the available options: married, single, widowed, divorced, or separated. Then, enter your age.
5. Input your driver's license information, including the state and number. This helps verify your identity.
6. Provide your primary and alternate addresses, making sure to include street name, apartment number, city, state, and ZIP code.
7. Fill in your home phone number and business phone number. You may also specify your religion if you wish.
8. Designate an emergency contact by providing their name, address, phone number, and your relationship to this person.
9. Indicate how you heard about the facility by selecting from options such as ad, friend, relative, referral, walk-in, internet, or Yellow Pages.
10. In the payment information section, identify the person responsible for the account and their relationship to you.
11. Provide the name of your primary insurer, along with the subscriber's name, ID number, date of birth, group number, and Social Security Number.
12. If applicable, fill out the information for your secondary insurer in the same manner as the primary insurer.
13. Read and complete the assignment and release section. This includes signing and dating the form to authorize medical benefits assignment.
14. If applicable, complete the Medicare authorization section, providing your signature and the date to authorize payment and information release.
15. Once all fields are filled out, review the form for accuracy. Save your changes, and you may choose to download, print, or share the completed form.

Start completing your Patient Demographics Form online today!