PATIENT INFO New/Update Date: __________

Name (Last)_____________________________ (First) _______________________ (Middle) __________

Address: ______________________________________________________________________________

City: __________________________________ State: _____________________ Zip: _______________

DOB: _____/_____/_____SS#: ________/_______/________Race: ________________Sex M F

Home#: (_____)_______-_______ Cell#: (_____)______-________ Marital Status: S M W D

Alternative Contact: ________________________________________Phone: ________________________

Patient's Employer: ________________________________________________Occupation:______________________

Address: ______________________________________________________Phone:____________________________

Spouse’s Name:__________________________________________________________________________________

DOB: _____/____/____ SS#:________/_________/_________

Spouse’s Employer:_______________________________________________Occupation:_______________________

Address: ____________________________________________________Phone:______________________

Referring MD:_____________________________________________Phone:__________________________

Address:___________________________________City_________________State:________Zip__________

PCP(If different from Ref. MD)______________________________________Phone:___________________

INSURANCE INFORMATION
PRIMARY INSURANCE COMPANY:__________________________________________________________

ID#:___________________________________________ GROUP#:________________________________

Primary Insured’s Name/Relationship:________________________________________________________
SECONDARY INSURANCE COMPANY:_______________________________________________________
ID#:___________________________________________ GROUP#:________________________________

Insured’s Name/Relationship: _______________________________________________________________

By signing below I hereby authorize Nephrology Associates to release any protected or individually identifiable health information to other Providers, Facilities, or, Individuals involved with my treatment or the payment thereof, as described in the privacy policies statement of Nephrology Associates. I further request that payment of authorized Medicare / Medigap / Medicaid / other insurance company benefits be made directly to Nephrology Associates for any service furnished to me, and hereby assign said benefits to them. I understand that I am required by law (Section 1128B SS Act & U.S.C. 3801-3812) to inform Nephrology Associates of any other party that may be responsible for paying for services provided to me.

_______________________________________________________________.
Signature of Patient/Guardian

Co-pays and deductibles are expected to paid at the time of service. Thank you!