New Patient Form - Diabetes Care Center of Louisiana

Patient Name *

Preferred Name

Address *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Home Phone *

Cell Phone *

Work Phone *

Social Security *

DOB *

Sex *

MaleFemale

Email Address *

Marital Status *

MarriedSingleWidowedDivorced

Employer/School Name *

Pharmacy *

Name *

Address *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Home Phone *

Work Phone *

Cell Phone *

DOB *

Social Security *

Email *

Employer *

Relationship to Patient *

Name of Insurance Company *

Name of Policyholder *

Policyholder Address *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Home Phone *

Work Phone *

Cell Phone *

Policyholder DOB *

Social Security *

Employer *

Policyholder ID# *

Group# *

Relationship to Patient *

Name

Phone

Relation

Name

Phone

Relation

How did you hear about us?

Word of MouthPhysician ReferralAdvertising/NewspaperSearch Engine/WebsiteInsurance Provider List

Assignment of Insurance Benefits: I hereby authorize Diabetes Care Center to provide medical care that is deemed necessary. I hereby authorize payment of benefits directly to Diabetes Care Center. I hereby authorize Diabetes Care Center to release any information necessary to process my claims. I acknowledge/understand that I am responsible for any charges incurred that my insurance does not pay for or cover for any reason whatsoever. I also acknowledge that if my account is turned over to a collection agency that I will be responsible for the collection fee towards my account. I also attest that the information that I have provided above is correct and truthful to the best of my knowledge.

e-Signature *

YesNo

Parent's/Guardian's Name *

Date *

Please fill out the form below.

Responsible Party

Insurance Information

Emergency/Alternate Contact Numbers

Verification