Clifton Family Medicine Reminders

Patient Name(Required)

Primary Phone(Required)

Email(Required)

Social Security Number:

Spouse/Partner Information

Spouse/Partner's Name:

Primary Phone

Emergency Contact Information

Emergency Contact's Name

Phone Number

Relation:

Insurance Information

Primary Insurance Company

Group Number:

Policy Number:

Member ID Number:

Policy Holder's Name:

Relation to Patient:

Policy Holder's SSN

Medical History

Reason:

If Yes, Please list:

Please list all Prescription Medications and over-the-counter medications including dosage:

Authorization

Submitted by:

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

Date

Patient Forms

Thank you for choosing CFM for your medical needs.

Spouse/Partner Information

Emergency Contact Information

Insurance Information

Medical History

Authorization