Get Person, By Us Mail, Or Confidential Fax:

Filling out the Person, By US Mail, Or Confidential Fax: form online is a straightforward process that helps in efficiently organizing and managing crucial patient information. This guide provides a step-by-step approach to ensure accuracy and ease when completing the form electronically.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the personal identification fields. Input your first name, middle name (if applicable), and last name along with your nickname. Then enter your date of birth, sex, and social security number in the designated fields.
3. Provide your mailing address, ensuring to include city, state, and zip code. This information should reflect the address where you can be reached.
4. Enter your preferred email address and indicate if you consent to receive emails regarding appointment reminders and healthcare updates.
5. List your school or employer details in the respective section, followed by your primary and alternate phone numbers. Specify if you would like to receive text reminders to either number by checking 'Yes' or 'No'.
6. Describe how you learned about Focus-MD by selecting an option such as Friend/Relative, Doctor Referral, or Internet Search.
7. Proceed to fill out the guarantor information, including their name, relationship to you, social security number, and contact details. Confirm if the mailing address is the same as yours.
8. If applicable, complete the insurance information section, detailing your insurance carrier, ID number, and policy holder's information. Repeat this for any secondary insurance coverage you may have.
9. Fill in the details of your primary care physician and any referring medical professional, if relevant. Provide their name, phone, fax, and address.
10. Finally, review all sections for accuracy. Once you have filled out the form completely, you can save your changes, download, print, or share the form as necessary.

Complete the necessary documents online today for a smoother patient experience.