Intake and Consent Form

Last Name *

First Name *

M.I.

Today's Date

Date of Birth *

Gender

Social Security Number

Home Phone

Cell Phone

Marital Status

Email Address *

Street Address *

City *

State

Zip

Employer

Work Phone

Emergency Contact

Emergency Contact Phone

Relationship to Patient

Primary Care Doctor

Primary Care Doctor Phone

Referring Doctor

Referring Doctor Phone

Preferred Local Pharmacy

Pharmacy Address

Preferred Mail Order Pharmacy

Insurance Information

Primary Insurance

Policy Number

Group Number

Name of Insured

Relationship to Patient

Insured Date of Birth

Secondary Insurance

Policy Number

Group Number

Name of Insured

Relationship to Patient

Insured Date of Birth

Please Sign Below Using Your Finger or Mouse

I hereby authorize payment of all insurance benefits directly to Pulmonary Associates of St Augustine. Any and all copays and coinsurances following insurance payments are due and payable by myself. *

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I authorize release of any information concerning my healthcare and any medical records requested by physicians providing my healthcare advice and treatment for the purpose of continuing care. *

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I have received and acknowledge HIPPA and privacy practices information. *

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Click here for Pulmonary Associates' HIPPA Policy

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