Patient Form
Patient Information Form
Email address *
Name: First MI Last *
Your answer
Address: Street, City, State Zip *
Your answer
Cell Phone: *
Your answer
Date of Birth: *
MM
/
DD
/
YYYY
Insurance Name: *
Your answer
Group Number *
Your answer
Insurance ID Number *
Your answer
Are you the insured? *
If no, please enter the name and date of birth of the insured.
Your answer
Who is your Primary Care Doctor and what is their phone number? *
Your answer
What is your pharmacy and phone number or cross streets? *
Your answer
Who referred you to Impression Foot & Ankle? *
Your answer
Assignment and Release: I certify that I, and or my dependent(s) have insurance coverage and assign all benefits directly to the office of Impression Foot & Ankle. I understand I will be responsible for any portion of the insurance claim that is denied or not covered by my insurance company.
Initial: *
Your answer
Release: I authorize the release to my insurance carrier any information necessary to process my insurance claims.
Initial: *
Your answer
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