Fillable INFO PATIENT RESPONSIBLE PARTY (If Minor Child)

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INFO PATIENT RESPONSIBLE PARTY (If Minor Child)

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The INFO PATIENT RESPONSIBLE PARTY (If Minor Child) form is 2 pages long and contains:

  • 5 signatures
  • 4 check-boxes
  • 43 other fields

Country of origin: OTHERS
File type: PDF

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PATIENT
INFO
Name (Last, First Middle & Maiden)
Street Address
Mailing Address
City / State / Zip
Home Number
Cell Number
Social Security Number
Date of Birth
Age
Sex
Marital Status
Spouse’s Name
Work Number
Email Address
RESPONSIBLE PARTY’S SIGNATURE / DATE
RESPONSIBLE PARTY (If Minor Child)
Responsible Party
Street Address
Primary Number
In Case of Emergency Contact
RESPONSIBLE PARTY (If Minor Child)
Responsible Party
Street Address
Primary Number
In Case of Emergency Contact
EMPLOYER INFORMATION
Employer
Street Address
City / State / Zip
Occupation / Job Title
INSURANCE INFORMATION
Primary Insurance Company
Policy Number / Group Number
Secondary Insurance Company
Policy Number / Group Number
INSURER INFORMATION
If other than card holder
Insurance Company or Insurer
Insurer Name
Date of Birth
HOW WERE YOUR REFERRED
Newspaper: ___________________________________
Yellow Pages: __________________________________
Doctor: _______________________________________
Other: ________________________________________
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I. MEDICARE LIFETIME SIGNATURE AUTHORIZATION
I request payment of authorized Medicare benets be made on my behalf. I assign the benets payable for physician services
to the physician or organization furnishing the services. I authorize any holder of medical information about me to release to
the health care nancing administration and its agents any information needed to determine these benets for related services.
Date: ______________________________ Signature: ______________________________________________________________________
II. MEDIGAP SIGNATURE AUTHORIZATION
I request payment of authorized Medigap benets be made on my behalf. I assign the benets payable for physician services
to the physician or organization furnishing the services. I authorize any holder of medical information about me to release to
the health care nancing administration and its agents any information needed to determine these benets for related services.
Date: ______________________________ Signature: ______________________________________________________________________
III. OTHER INSURANCE SIGNATURE AUTHORIZATION
I request payment of authorized benets be made on my behalf. I assign the benets payable for physician services to the
physician or organization furnishing the services. or authorize such physician or organization to submit a claim to my insurance
company for me.
Date: ______________________________ Signature: ______________________________________________________________________
IV. AUTHORIZATION FOR RELEASE OF INFORMATION
i hereby authorize all physicians, providers, and health care facilities that have provide health care services to me or my
dependents to release any information relating to the diagnosis, treatment, or examination rendered. i agree that a
photographic copy of this authorization shall be as valid as the original.
Date: ______________________________ Responsible Party Signature: ____________________________________________________
Date: ______________________________ Witness: _______________________________________________________________________
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INFO PATIENT RESPONSIBLE PARTY (If Minor Child)

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Completed 22 March 2022

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