FORT DAVIS FAMILY PRACTICE
PATIENT INFORMATION FORM

Hello, and thanks for selecting Fort Davis Family Practice for your medical needs.

To expedite your first visit, we offer this online Patient Information Form. If you would like to fill it out ahead of time, it will save you some time on your first visit. If not, we will have a printed form you can fill out in person.

Thank you.

Date: Choose Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2007 2008 2009 2010

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PATIENT INFORMATION

Last Name: First Name: M.I.

Street: Apt.# 

City: State Zip:

Home Phone: ( )

Work Phone: ( )  Ext.

Date of Birth: Choose Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Sex: Male Female

Social Security Number:  

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Allergies:

Insurance Type (i.e. Blue Cross, Blue Shield, Aetna):

Policy Holder Last Name: First Name:

Relationship to Insured:

Policy Number:

Group Number:

Policy Dates:

Designated Doctor:

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Workman's Comp. Information:

Is your condition related to: Employment, Auto/Other,

 Date of Injury: Choose Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2002 2003 2004 2005 2006 2007 2008 2009 2010

Please give complete information if this is Workman's Comp!

I hereby instruct you to pay directly to James D. Luecke, M.D. for professional services rendered, otherwise payable to me for such services. This is an assignment of my rights under my medical coverage to the extent of such bills. Any sum of money paid to them under this agreement shall be credited to my account. I understand I am responsible for any balance the insurance company does not cover. If I am not covered by any insurance, I understand that I am responsible for all charges.

Signature of Patient/Responsible Party: ______________________________________________

Medicare Patients only:

I request that payment of authorized Medicare benefits be made by either to me or on my behalf to me to release the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services.

Signature of Patient/Responsible Party: ______________________________________________

Consent to treat minor in absence of parent:

I hereby authorize Dr. James D. Luecke or his physician assistants employed at Ft. Davis Family Practice to render medical treatment to my daughter/son in my absence whether she/he comes in alone or is brought in by any other person other than myself.

Signature of Parent/Legal Guardian: ______________________________________________

Date: _________________________

I hereby authorize the release of my medical records or copies of such and request that they be transferred to Fort Davis Family Practice.

Signature of Patient: ______________________________________________

I understand that this office will submit claims to my insurance company for me, but that I am ultimately responsible for my account.

Signature of Patient: ______________________________________________