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KEVIN TEAL M.D., P.C. 4833 Integris Parkway Suite 150 Edmond, OK 73034-8864 Phone /Fax: 855-457-8674 www.krtnsg.com

New Patient Financial Intake Form

Registration Form Today’s date:

PCP:

PATIENT INFORMATION Patient’s last name:

First:

Middle:

 Mr.  Mrs.

Home phone no.:

Cell phone no.:

Employer phone no.:

(

(

(

)

)

 Miss  Ms.

Birth date:

Occupation:

Employer:

Age:

/

Apt. #:

City:

Single / Mar / Div / Sep / Widow

)

Street address:

P.O. box:

Marital status (circle one)

Sex: M

/

F

Social Security no.:

State:

ZIP Code:

Pharmacy Name & #: (

Referred to clinic by (please check one box):

 Dr.

)

 Insurance Plan

 Hospital Name:

INSURANCE INFORMATION Person responsible for bill:

Birth date: /

Is this person a patient here? Occupation:

Address (if different):

Home phone no.:

/

 Yes

(

)

 No

Employer:

Employer address:

Employer phone no.: (

Is this patient covered by insurance? Primary Insurance  Medicare

 Yes

 No

 BCBS  Community Care

Subscriber’s name:

 United  GlobalHealth

Subscriber’s S.S. no.:

 Tricare

 Self

Name of Secondary Insurance (if applicable):

Patient’s relationship to subscriber:

 Self

 Spouse

Birth date:

 Child

 Aetna

 Other Group no.:

Policy no.:

Co-payment:

/

$  Other

Subscriber’s name:

 Spouse

 Worker Comp.

 Coventry

/ Patient’s relationship to subscriber:

)

Group no.:

 Child

Policy no.:

 Other

IN CASE OF EMERGENCY Name of local friend or relative (not living at same address):

Relationship to patient:

Home phone no.:

Work phone no.:

(

(

)

)

I authorize the release of any information including the diagnosis and the records of any treatment or examination rendered to my child or me during the period of such care to third party payers and/or other health practitioner. The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize KEVIN TEAL M.D., P.C. or insurance company to release any information required to process my claims.

Patient/Guardian signature

Date


New Patient Financial Intake Form  

Financial Data Form

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