Patient InformationPatient Name* First Last Patient Preferred Name* Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physical Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Telephone Number*Secondary Telephone NumberEmail* Social Security Number Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex at Birth*(check what applies) Male Female Gender Identity*(check what applies) Male Female Trans Male (FTM) Trans Female (MTF) Other I Choose Not to Disclose Sexual Orientation*(check what applies) Straight (not Gay) Gay or Lesbian Bisexual Something Else Don't Know I Choose Not to Disclose Marital Status*(check what applies) Single Married Divorced Widowed Separated Race*(check what applies) I Choose Not to Disclose Indian/Alaskan Native Asian Black/African American Native Hawaiian White/Caucasian Pacific Islander Ethnicity*(check what applies) Hispanic or Latino Not Hispanic or Latino I Choose Not to Disclose Language Preference*(check what applies) English Spanish Highest Level of Education*(check what applies) Less than High School degree High School diploma or GED More than High School I Choose Not to Answer this Question Patient Occupation* Patient is a Minor* Yes No Patient is a Seafood Worker* Yes No Annual Household Income*(check what applies) $0 - $10,000 $10,001 - $15,000 $15,001 - $20,000 $20,001 - $25,000 $25,001 - $30,000 $30,001 - $35,000 $35,001 - $40,000 $40,001 - $45,000 $45,001 - $50,000 $50,001 - $55,000 $55,001 - $60,000 $60,000 + How many family members, including yourself, do you currently live with?*Emergency Contact* First Last Phone Number*Relationship to Patient* Person Financially Responsible if Not Patient First Last Phone NumberRelationship to Patient Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What is Your Main Insurance?*(check all that apply) None/uninsured Medicare Medicaid BCBS Medcost Tricare United Health Care Other Private Insurance Insurance Policy / Member ID Group ID File Upload - Upload Pictures of Insurance Card, front and back, and Your Drivers License (front) Drop files here or Select files Max. file size: 5 GB. ConsentCONSENT FOR GENERAL MEDICAL TREATMENT* I authorize the employees of ENGELHARD MEDICAL CENTER (EMC) to render primary care and related services. I understand that EMC is committed to offering superior quality of care to all patients regardless of race, ethnicity, religion, sex, age, or handicap status. I understand that I will be fully informed of anticipated benefits, possible discomforts, and potential side effects prior to the performance of any medical treatment, and I release EMC from liability that may arise as the result of such treatment, unless due to sole negligence of its staff. I consent to examinations, treatments, procedures and blood tests ordered by my physician and health care providers, including blood tests for communicable diseases such as hepatitis and HIV/AIDS.MEDICARE PATIENTS: SIGNATURE ON FILE* I request payment of authorized Medicare benefits be made either to me or on my behalf to ENGELHARD MEDICAL CENTER for any services furnished me by the listed provider / supplier. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable to related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If “other health insurance” is indicated on approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency. In Medicare assigned cases, the provider or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and noncovered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier.ASSIGNMENT OF INSURANCE BENEFITS* I hereby assign all medical and / or surgical benefits, to include major medical benefits to which I an entitled, private insurance, and any other health plans to ENGELHARD MEDICAL CENTER. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information necessary to secure the payment.FINANCIAL POLICY FOR PAYMENT AND DISCOUNT PLAN MVP* Services rendered are expected to be paid for on the date of service. Sources of acceptable payments are Cash, Check, Medicare, Medicaid, Champus, Private Insurance, debit card, Major Credit cards (MasterCard, VISA). If you need help paying this bill, you may qualify for the sliding fee scale discount plan MVP. The sliding fee scale is based on your household size and income. I have read, understood, and agreed to this financial policy for payment of professional fees. The patient is ultimately responsible for all professional fees.NOTICE OF PRIVACY PRACTICES RECEIVED* I acknowledge that I was provided with the Notice of Privacy Practices of the ENGELHARD MEDICAL CENTER.Signature* Reset signature Signature locked. Reset to sign again Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
