Its Lowkey A Game Im Not Sure What Game But I Need Access And Im Not Paying Emerson And English Assignment

1795 words - 8 pages

2705 E 17TH ST • Ammon, ID 83406 • 208.346.7500 • fax 208.346.7501
Patients Information: Today’s Date: _____________
First Name: ______________________ Middle Name: ______________________ Last Name: _____________________
Note: Please spell name exactly as spelled on your insurance card.
Street Address: ______________________________ City: ____________________ State: __________ Zip: __________
Home Phone: __________________ Cell Phone: __________________ Email: __________________________________
DOB: _____________Age: ____ Gender: ___________ Gender Identity: ___________ Sexual Orientation: ___________
SS#: _________________Primary Language: _________________________ Do you need an interpreter? Y ____ N ____
Marital Status - Single: ____ Married: ____ Divorced: ____ Separated: ____ Partner: ____ Widow: ____ Other: ______
Note: If divorced, please supply Pearl Health Clinic with legal documentation of custody to ensure that privacy rights can be enforced.
Ethnicity: Native American ____ African American ____ Latino ____ Asian ____ Pacific ____ Caucasian ____ Other ___________.
Parent(s)/Guardian(s): **The person completing the intake packet must be listed first**
1st Parent/Guardian Full Name: _______________________________ DOB: ______________ SS#: _________________
Are you the Insured Party? Y ____ N ____ Relationship to Client: __________Employer: _________________________
2nd Parent/Guardian Full Name: ______________________________ DOB: ______________ SS#: _________________
Are you the Insured Party? Y ____ N ____ Relationship to Client: __________Employer: _________________________
Emergency Contact: ___________________________ Home Phone: _______________ Cell Phone: ________________
Insurance Information: **Accurate information is essential to providing timely care**
**Please bring insurance cards to 1st appointment**
If you have more than two insurance carriers, please bring that information with to your 1st appointment.
Primary Insurance Carrier:
Name: ______________________________________
Phone: _____________________________________
Policy Holder (PH): ___________________________
Relationship of PH to you: _____________________
PH DOB: ____________ PH SS#__________________
Policy ID#: __________________________________
Group#: ____________________________________
Secondary Insurance Carrier:
Name: ______________________________________
Phone: _____________________________________
Policy Holder (PH): ___________________________
Relationship of PH to you: _____________________
PH DOB: ____________ PH SS#__________________
Policy ID#: __________________________________
Group#: ____________________________________
2705 E 17TH ST • Ammon, ID 83406 • 208.346.7500 • fax 208.346.7501
Sliding Scale Plan: Page 2
*If you are without insurance, you may opt to see an Intern (based on availability) or apply for our sliding scale program. To apply for the Sliding
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