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Digestive Health Associates & Center of Reno
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Patient Information Form
Patient Information Form
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655 Sierra Rose Drive
Reno, Nevada 89511
Phone (775) 829-7600
Billing 1-866-978-6912
Fax (775) 829-3757
www.digestivehealthreno.com
HOW DID YOU HEAR ABOUT OUR PRACTICE?
REFERRAL
PRIMARY CARE DOCTOR
INTERNET
MEDIA
FRIEND
REFERRING PHYSICIAN
ACCOUNT #
PATIENT INFORMATION
Patient’s Last Name
First
Initial
Age
Date of Birth
Social Security #
Address
City
State
Zip
Home Phone #
Marital Status
Single
Mar
Div
Sep
Wid
Business Phone #
Cell Phone #
Patient’s Email Address
Patient’s Employer
Occupation
SPOUSE/GUARDIAN INFORMATION
IS YOUR SPOUSE/GUARDIAN CURRENTLY WORKING?
YES
NO
RETIRED?
YES
NO
DOES PATIENT HAVE COVERAGE UNDER SPOUSE/GUARDIAN?
YES
NO
Last Name
First
Initial
Date of Birth
Social Security #
INSURANCE INFORMATION
CURRENTLY INSURED?
YES
NO
PRIMARY INSURANCE COVERAGE
Insured’s Name
Policy or Member ID #
Group #
Insurance Company Name & Address
Co-Pay Amount
Employer
Relationship to Patient
SECONDARY INSURANCE COVERAGE
Insured’s Name
Policy or Member ID #
Group #
Insurance Company Name & Address
Co-Pay Amount
Employer
Relationship to Patient
AUTHORIZATION TO RELEASE MEDICAL INFORMATION/INSURANCE BENEFITS
I authorize my insurance benefits to be paid directly to Digestive Health Associates/Digestive Health Center. I am financially responsible for any balance due. I authorize Digestive Health Associates/Digestive Health Center to release any information required for payment of this bill. A copy of this is as valid as the original. If my insurance requires a referral, I understand it is my responsibility to obtain this.
I authorize my insurance benefits to be paid directly to Digestive Health Associates/Digestive Health Center. I am financially responsible for any balance due. I authorize Digestive Health Associates/Digestive Health Center to release any information required for payment of this bill. A copy of this is as valid as the original. If my insurance requires a referral, I understand it is my responsibility to obtain this.
I agree to the authorization.
Date
MM slash DD slash YYYY
PATIENT INFORMATION
Acct #
Date
MM slash DD slash YYYY
NAME
DATE OF BIRTH
RACE
*
AMERICAN INDIAN OR ALASKA NATIVE
ASIAN
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
BLACK OR AFRICAN AMERICAN
WHITE
OTHER RACE
DECLINED TO SPECIFY
RACE (Other)
*
ETHNICITY
*
HISPANIC OR LATINO
NOT HISPANIC OR LATINO
DECLINED TO SPECIFY
PRIMARY LANGUAGE
*
ENGLISH
SPANISH
OTHER
DECLINED TO SPECIFY
PRIMARY LANGUAGE (Other)
*
SEXUAL ORIENTATION
LESBIAN, GAY OR HOMOSEXUAL
STRAIGHT OR HETEROSEXUAL
BISEXUAL
SOMETHING ELSE, PLEASE DESCRIBE
DON’T KNOW
DECLINED TO SPECIFY
SEXUAL ORIENTATION (SOMETHING ELSE, PLEASE DESCRIBE)
GENDER IDENTITY
IDENTIFIES AS MALE
IDENTIFIES AS FEMALE
FEMALE-TO-MALE (FTM) / TRANSGENDER MALE / TRANS MAN
MALE-TO-FEMALE (MTF) / TRANSGENDER FEMALE / TRANS WOMAN
GENDERQUEER, NEITHER EXCLUSIVELY MALE NOR FEMALE
ADDITIONAL GENDER CATEGORY OR OTHER, PLEASE SPECIFY
DECLINED TO SPECIFY
GENDER IDENTITY (ADDITIONAL GENDER CATEGORY OR OTHER, PLEASE SPECIFY)
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