Beaver Family Clinic

ATTENTION:
This form below is only for NEW PATIENTS or for patients that do NOT have a Digital Office username and password login.

If you know your Digital Office login, please LOGIN now to access your information.

If you would like to download a printable version of this form, please go to our Document Center to access our printable forms.

Patient Information

Please enter your personal information below.

First Name

Last Name

Birth Date (ex:mm/dd/yr)

Social Security #

Driver's License #

Marital Status

Mailing Address

City State

Zipcode

Home Phone

Work Phone

Cell Phone

Occupation

Employer

Patient's Spouse Information

Please enter your spouse's or significant's other information below.

First Name

Last Name

Birth Date

Social Security #

Work Phone

Cell Phone

Occupation

Employer

Emergency Contact Information

Please provide emergency contact information, other than your spouse.

Relationship

Phone

Address

Insurance and Billing Information

Medicare ID

Medicaid ID

Primary Coverage

Insurance Company

Effective Date

Subscriber's Name

Subscriber's DOB

ID # or SSN

Group ID

Relationship to Subscriber

Secondary Coverage (optional)

Insurance Company

Effective Date

Subscriber's Name

Subscriber's DOB

ID # or SSN

Group ID

Relationship to Subscriber

ASSIGNMENT OF INSURANCE BENEFITS

By checking the box below; I hereby authorize direct payment of medical/surgical benefits to Beaver Family Clinic for services rendered by the physicians, physician assistants, and other medical personnel. I understand that I am financially responsible for any balance not covered by my insurance.
I agree to this assignment

AUTHORIZATION TO RELEASE INFORMATION

By checking the box below; I hereby authorize Beaver Family Clinic to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefits. I further authorize release of all medical records to other physicians that may be taking care of me for referrals, surgery, etc.

I certify that the information I have provided is true and correct.
A PHOTOCOPY OF THESE ASSIGNMENTS SHALL BE VALID AS THE ORIGINAL.

I hereby give Beaver Family Clinic and its physicians, my consent for any necessary medical evaluation and treatment.
I agree to this authorization
Patient's Name

Parent/Guardian's Name

Dated