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