DOYLESTOWN THYROID AND ENDOCRINE ASSOCIATES Patient Demographics Electronic Form Email * Cell Phone * Date of Visit Patient’s name * Date of Birth * Address * Home Phone Work Phone Referred by Family Doctor & phone Gender MALEFEMALE Marital Status SingleMarriedDivorced/SeparatedWidowed Emergency contact name and phone # * Relationship Guardian name (if required) Medical Insurance Info * ID# Group Number Subscriber’s name Subscriber’s date of birth Relationship to subscriber Secondary Insurance ID# Group Number Subscriber’s name Pharmacy name and address Pharmacy phone I hereby authorize Doylestown Thyroid & Endocrine Associates to release any information necessary to insurance carriers to process claims. I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any balance remaining after submission to my insurance. I have received and reviewed the practice’s Financial Policies and Procedures By submitting this form, I am acknowledging that Doylestown Thyroid and Endocrine Associates provided to me information about its Notice of Privacy Practices. This notice provides information about how we may use and disclose your protected health information. I have received and reviewed this practice’s Notice of Privacy Practices.
