Patient Information Form Download Form Patient Information Full Name (Required) Preferred Name Date of Birth (Required) Social Security Number (Required) Address (Required) City (Required) State (Required) Zip (Required) Email Address (Required) Home Phone # Work Phone # Cell Phone # May we leave a message on your home or cell phone? —Please choose an option—YesNo Emergency Contact Name (Required) Relationship (Required) Phone # (Required) How Did You Hear About Us? Primary Insurance Policy # Group # Policy Holder Date of Birth Relationship to Patient Insurance Co. Name Insurance Co. Phone # Insurance Co. Address Secondary Insurance Policy # Group # Policy Holder Date of Birth Relationship to Patient Insurance Co. Name Insurance Co. Phone # Insurance Co. Address I understand that payment is due at the time service is rendered. I hereby authorize the release of any medical information to my insurance company through which I claim benefits. I hereby assign all benefits that I am entitled, including Medicare, private insurance, group policy benefits, or other health plans to Rhett Women’s Center. I understand that I am financially responsible to Rhett's Women's Center for all charges not covered, approved or consid-ered necessary by my insurance company. I will pay at the time of service or have an agreeable payment arrangement set up with the business office. I understand the above terms
