Get Patient Information Form - Comprehensive Spine ... - Comprehensivespine

This guide provides users with clear and supportive instructions on filling out the Patient Information Form for Comprehensive Spine. By following these steps, users can ensure their form is completed accurately and efficiently.

Follow the steps to complete your Patient Information Form.

1. Click 'Get Form' button to access the Patient Information Form and open it for editing.
2. Begin with the Patient Information section. Fill in the account number, name, date of birth, street address, social security number, city, state, zip code, work phone, sex, home phone, cell phone, marital status, spouse's name, spouse's work phone, spouse's cell phone, the individual who referred you, and your primary care physician's name.
3. Next, fill out the Guarantor (Responsible Person) Information section. Provide the name, date of birth, social security number, state, zip code, street address, city, home phone, cell phone, and email address. Include the guarantor's employer name and phone number with the address and city/state.
4. In the Health Insurance Information section, start with the Primary Insurance details. Specify the insurance provider's name, your ID number, group number, name of the insured, and their relationship to you. If applicable, also fill in the Secondary Insurance details.
5. For the preferred pharmacy, indicate the name, city, and phone number of the pharmacy where prescriptions should be called.
6. Move on to the Emergency Contact Information. Provide the name, relationship to you, address, city, state, daytime phone, and cell phone of your emergency contact.
7. Review the Authorization section carefully. Initial each statement to affirm your understanding of the terms, including consent for treatment, responsibility for payment, and authorization for information release.
8. Sign and date the form, ensuring you also include your printed name and relationship to the patient.
9. Finally, ensure all information is complete and accurate. You can then save the changes made, download the form, print it for physical records, or share it as needed.

Complete your Patient Information Form online today for a smoother experience with Comprehensive Spine.