PATIENT INFORMATION SHEET
PLEASE PRINT
Patient Name:
_______________________________ _______ _______________________________ _____
First Middle Initial Last Suffix
Date of Birth: ______________ Gender: Male Female
Mailing Address: ______________________________________________________________ ______________
Please enter address where you receive your mail Apt./Lot/Unit #
City: _________________________________ State: ______________________ Zip: ______________
Home Phone: ____________________ Alternate phone: __________________ Cell phone: __________________
May we leave confidential messages at any of these numbers? Yes No
Email Address: _________________________________________________________________________
Emergency contact name: ____________________________ Phone #: ______________________________
GUARANTOR / PERSON RESPONSIBLE FOR THIS ACCOUNT PATIENT EMPLOYER INFORMATION (Worker’s Comp cases)
Name: __________________________________________ Employer Name: __________________________________
Relationship to patient: ____________________________ Business Phone: __________________________________
Phone: _________________________ DOB: ___________ Employer Address: ________________________________
Mailing Address: __________________________________ City: ___________________ State: _______ Zip: ________
City: ___________________ State: _______ Zip: _______ Date of Injury: ____________________________________
Claim #: _________________________________________
INSURANCE POLICY HOLDER INFORMATION
PRIMARY Policy Holder Name: _______________________________________ Patient relationship: ________________________
Address (include city, state, zip): ___________________________________________________________________________________
DOB: _____________________________ Gender: _____________
SECONDARY Policy Holder Name: _______________________________________ Patient relationship:
_______________________
Address (include city, state, zip): ___________________________________________________________________________________
DOB: _____________________________ Gender: _____________
Are you currently receiving Skilled Nursing or Hospice Care?
Yes No Provide name of nursing facility: __________________
RELEASE/AUTHORIZATION OF MEDICAL INFORMATION
All information in our office is kept confidential. Please list names of anyone whom you authorize our office to discuss your medical
condition, treatment, radiology results, appointments, billing, insurance benefits and/or to obtain copies of films, CD’s or reports. If you
want your information to remain confidential please write “NONE”. Baptist M&S Imaging may request healthcare information from other
healthcare providers for continuation of my care. (Films, CD’s, Pathology results and reports related to Imaging). Baptist M&S Imaging may
also share my health information with medical providers, other than my referring provider, for healthcare needs.
Name
________________________________
________________________________
Relationship
________________________________
________________________________
Phone Number
________________________________
________________________________
It is your responsibility to notify our office if this information changes.
Patient/Guardian Printed Name Patient/Guardian Signature Date
______________________________ ___________________________________ ________________________
