Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient’s last name in the designated field under 'Name'. Then, provide the patient’s first name and date of birth using the format MM/DD/YYYY.
3. Input the patient phone number in the specified format. Provide the patient’s home zip code for insurance purposes.
4. Select the payment type by choosing either 'Cash client' or 'Has insurance'.
5. Indicate the patient’s gender by selecting 'M' for male or 'F' for female.
6. Fill in the patient’s Social Security number and e-mail address in the respective fields.
7. Enter the primary physician’s name during the patient’s stay at the facility.
8. Specify if the patient is a smoker by selecting 'Y' for yes or 'N' for no.
9. Provide the insurance provider details along with the insurance contact number, BIN, PCN, ID, and group numbers.
10. State the relationship to the subscriber, such as 'father', 'child', or 'spouse'.
11. List any known allergies in the space provided.
12. Attach a photocopy of the patient’s ID and insurance card on one page, as well as the signed and dated HIPAA form.
13. If applicable, include the signed and dated credit card authorization form for payment of medications or co-pays.
14. Once all fields are filled, review the form for accuracy before saving changes, downloading, printing, or sharing.

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