Get New Patients Please Complete The Following Forms And Bring Them ...

Completing the New Patients form is a crucial step in preparing for your first appointment with a MedBank Case Specialist. This guide provides clear, step-by-step instructions to help ensure you provide all necessary information efficiently and accurately.

Follow the steps to complete the forms online

1. Press the ‘Get Form’ button to download the form and open it in your preferred editing tool or application.
2. In the first section, enter your last name, first name, and middle name as requested. Ensure these names match your identification documents.
3. Provide your total number of household members, including adults and children. This information is essential for assessing your eligibility for assistance.
4. Fill in your state, home phone number, county, and ZIP code to ensure the MedBank can reach you easily.
5. In the street address section, input your complete residential address, along with the city you reside in.
6. List any allergies you may have in the designated space, as this information is vital for your health management.
7. Indicate if you qualify for any governmental assistance programs such as Medicaid or Medicare by checking the appropriate boxes.
8. Complete your marital status by selecting from the provided options. This will help MedBank tailor their services to your situation.
9. Fill in your social security number and birthdate, ensuring accuracy to facilitate seamless processing of your information.
10. If applicable, indicate whether you identify as a person with a disability and if you are a veteran by checking the corresponding boxes.
11. Provide emergency contact information, including the name and phone number of the person to notify in case of an emergency.
12. Review the patient responsibilities section, ensuring you understand and agree to the obligations outlined within it.
13. Sign and print your name to confirm that the provided information is accurate and complete. Ensure to also obtain your guardian's signature if applicable.
14. After completing the form, you can either save any changes, download the form to keep a copy, print it for your records, or share it with the necessary parties.

Complete your forms online today to expedite your appointment with MedBank!