Weaverville Family Medicine Personal Information Form
Please print this form. Then fill it out, and bring it with you to your appointment.
We know that your time is precious. To avoid spending time in the waiting room filling
out paperwork, please bring this form completed with you to your first appointment.
Personal Information:
Patient's Name: First __________________________ MI _____ Last __________________________
Home address __________________________ City ____________________ State _____ Zip ________
Mailing address _________________________ City ____________________ State _____ Zip _______
Home Phone#(_____)__________________ Cell Phone # (____) _________________
Date of Birth ______________________ SS#:_________________________
Employment Information Employer Name: ___________________________ Work #:______________
Insured through your employer ?: Yes/No Status: Full Time/Part Time/Retired/Student
Minor Child(under 18):
Responsible Parent's Name: _________________________ Employer ____________________________ Work#:_________________SS#:________________ Date of Birth:_________ Relationship: ______________________________
Please Circle One of the following choices:
Gender: Male / Female / Other Marital status: Married / Single / Widowed / Separated / Divorced Race: American Indian or Alaskan Native/ Asian/ Black/African American /More than one race Native Hawaiian/ Other Pacific Islander /White
Ethnicity: Hispanic/Latino -- Not Hispanic/Latino
Preferred language: ____________________________________
Birth Country / State: ______________________ e-mail address: ___________________________ None
Medical Insurance Information: Please provide insurance card!
Primary Insurance Information:Insurance Company _____________________________________
Name of Insured ______________________ Date of birth _________ SS#___________________
Insured's Employer: ________________________ ID# __________________ Group # ____________
Patient's relationship to Insured: ____________________________________ Secondary Insurance Company: Name _________________________________________________
Name of Insured ________________________________ Date of birth __________________________
Insured's Employer: ________________________ ID# __________________ Group # ____________
Patient's relationship to Insured: ____________________________________
Emergency contact:
Name _____________________ Phone number _________________ Relationship: ________________
Authorization to Release Information and Assignment of Benefits I hereby give consent for treatment and accept responsibility for the full amount of the charges incurred for my treatment. I authorize Weaverville Family Medicine Associates to furnish information to my insurance carriers concerning my treatment and I hereby assign Weaverville Family Medicine all payments for medical services rendered to myself/my dependants. I understand that I am responsible for any amount not covered by the insurance carrier. I authorize the use of photo static copy of this statement in lieu of the original when necessary. This serves as a lifetime authorization unless revoked by me in writing.