Patient Forms

Patient Information Form

If you have an appointment with our office, please completely fill out the form and bring it with you to your appointment, along with your insurance card(s) and your co-pay, if any.

Patient Information

Please fill out all relevant fields

Name

Date of Birth*

Sex

Male
Female

Primary Address

Mailing Address

(If different than primary address)

Home Phone

Other Phone

Email Address

Emergency Contact Information

Name

Phone

Relationship

Insurance Information

Primary Insurance

Policy #

Policy Holder

Group #

Phone

Secondary Insurance

Policy #

Policy Holder

Group #

Phone

Authorization for Release Information

I am authorizing VIP Fibroid Center to release all medical information (including, but not limited to, information on psychiatric conditions, alcohol and drug abuse) requested by my health insurance carrier, Medicare or any other third-party payers. I authorize VIP Fibroid Center to release all medical information on to my referring physician and my primary physician. I authorize VIP Fibroid Center to contact my insurance company or health plan administrator and obtain all pertinent financial information concerning coverage and payments under my policy. I direct the insurance company or health plan administrator to release such information to VIP Fibroid Center.

Assignment of Benefits: I request that payment of authorized insurance benefits be made on my behalf to VIP Fibroid Center. I agree that these provisions will remain in effect until I provide written revocation to VIP Fibroid Center.

Patient/Guardian Signature

Today's Date*

Guardian Name

if applicable

Choose a Location

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