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Mercer Internal Medicine, LLC

Guy Nee, MD, FACP     Michael H. Yamane, MD, MPH, FACP

2480 Pennington Road     Suite 104     Pennington, New Jersey    08534

    Tel: (609) 818-1000     Fax: (609) 818-9800   

www.MercerInternalMedicine.com

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


Print out this form to complete. Mail, fax, or bring the completed form to the office.

Patient Information Sheet                                                    Mercer Internal Medicine, LLC

Name:_______________________________________________________________________________

Address:_____________________________________ City:_____________ State:____ Zip:_______

Home Phone:____________________________ Work Phone:_______________________________

Cell Phone:______________________________ Call this number first: __Home  __Work  __Cell

Birthdate:______________________ Sex: M F        Social Security #:________________________

Occupation:___________________________ Employer:____________________________________

Referred by:_________________________________________________________________________

Names of parents:___________________________________________________________________

Race:_______________________________     Ethnicity:____________________________________

Primary Medical Insurance Company:__________________________________________________

Subscriber's Name & Relationship:_____________________________________________________

Policy/ID #:_______________________________________ Group #:________________________

Secondary Medical Insurance Company:________________________________________________

Secondary Subscriber's Name & Relationship:__________________________________________

Policy/ID #:_______________________________________ Group #:________________________

Other Insurance?_____________________________________________________________________

Marital Status: Single Married Widowed Divorced Separated

Name of Spouse:_________________________________ Spouse's Date of Birth:______________

Spouse's Employer:______________________________ Spouse’s Work Phone #:_____________

Spouse’s Social Security #:____________________________________________________________

In case of emergency, contact:_______________________________________________________

Address:___________________________________________________________________________

Phone #’s:__________________________________________________________________________

Please read, sign, and date the following to allow us to bill your insurance company for your medical care: I hereby authorize Mercer Internal Medicine, LLC to furnish information to insurance Carriers concerning my illness and treatments and hereby assign to these physicians all payments for medical services rendered to myself or my dependents.  I also acknowledge that I have reviewed the Mercer Internal Medicine Patient Privacy Policy and Office Policies statements.

Signature:_______________________________________________ Date:______________________

Initial and circle year reviewed and updated:   ___2013   ___2014