How did you hear about our office? __________________________________________

LAST NAME:______________________ FIRST: _____________________ MI: ______

ADDRESS: _____________________________________________________________

CITY: ____________________________ ZIP: ______________________________

HOME PHONE: _____________________ WORK PHONE: ____________________
HAVE YOU EVER BEEN SEEN BY A PHYSICIAN IN THIS OFFICE IN THE PAST? Y N
IF SO, WERE YOU SEEN UNDER ANY OTHER NAME THAN ABOVE? Y N
OTHER NAME: _______________________________________________

DATE OF BIRTH: ____________________ SOCIAL SECURITY #_____________________

SEX: M F MARITAL STATUS: SINGLE MARRIED WIDOW DIVORCED

SPOUSE LAST NAME: __________________________ FIRST: _________________________

SPOUSE DATE OF BIRTH: _______________SOCIAL SECURITY #____________________

CHILDREN Y N NUMBER OF CHILDREN________ Children included in request Y N

NAMES AND AGES OF CHILDREN: ______________________________________________

CURRENT PHYSICIAN: ________________________________________________________

REASON FOR LEAVING: _______________________________________________________

EMPLOYER: SELF: ___________________________ SPOUSE: ________________________

INSURANCE: Y N MEDICAID Y N MEDICARE Y N OTHER INSURANCE Y N

(MEDICAID) NUMBER ON CARD: _______________________________________________

INSURANCE CO NAME: ________________________________________________________

POLICY NUMBER: ______________________ EFFECTIVE DATE OF COVERAGE_______

KOSCIUSKO FAMILY HEALTHCARE PHYSICIAN YOU ARE REQUESTING:

PARK SNIDER SAWYER MACDONALD WHITNEY PITTS

PAYMENT ARRANGEMENTS ARE AS FOLLOWS: OUR OFFICE EXPECTS PAYMENT IN FULL AT TIME OF SERVICE, IF WE ARE CONTRACTED WITH YOUR INSURANCE COMPANY WE WILL FILE YOUR CLAIM FOR YOU BUT EXPECT PAYMENT OF CO-PAY AT TIME OF SERVICE.
I UNDERSTAND AND AGREE TO ABIDE BY THE PAYMENT POLICIES OF KFH

__________________________________________________ ________________________________________________________
DATE SIGNATURE