Appointment – Harbor Phsyicians

Name *

First

Last

Date of Birth *//

Social Security Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Sex *

Male
Female

Email Address *

Cell Phone Number: *

Home Phone Number:

Employer

Work Number:

Emergency Name *

First

Last

Date of Birth *//

Relationship to Patient:

Cell Phone Number: Emergency *

Home Phone Number: Emergency

Name of Insurance:

ID Number:

Group Number

Effective Date://

Patient's Relationship to Subscriber:

Subscriber's Name:

Subscriber's Date of Birth://

Payment is due at time of service. We collect payment for services before your visit. Any remaining balance due will be collected upon checkout. After submitting the claim to insurance, if any remaining patient responsibility exists, you will receive a bill.
If you wish for us to file your medical insurance, you must provide us with a current copy of your insurance card.
If we are unable to obtain verification of your benefits from your insurance company, you will be required to pay the full amount due, at the time of service.
If your insurance denies your claim, you will be responsible for any remaining balance. While we will do our best to obtain your benefits from your insurance company, you are ultimately responsible for knowing your insurance coverage information. For example, what your plan does and does not cover; any deductibles, co-insurance, or co-pays you are responsible for.
If we cannot fully verify your health plan coverage or benefits from your insurance company, we reserve the right to bill you for any additional amount your insurance company informs us is assigned to patient responsibility after processing your claim. If you do not possess health insurance and are "self pay", you are responsible for the full amount due at the time of service.
By electronically signing below, I authorize the release of any medical and personal information necessary to process claims for medical services rendered. I also request payment of government benefits either to myself or the party who accepts assignment. I authorize payment of medical benefits to Harbor Physicians for any services rendered, medical equipment, and products used in my care and treatment.
By electronically signing below, I am agreeing to all the terms above and that I understand that I am responsible for payment at the time when services will be rendered. I also understand that my total when checking out is an estimate of my financial responsibility, and give Harbor Physicians the right to bill me for any remaining balance that may result after the insurance company has processed my claim. Finally, I understand that any unpaid balance may result in my personal information being sent to a collections company, for the purpose of collecting my past due debt.

If cancer was selected, provide details:

Type, stage, surgery, current status, etc

List any other Medical Conditions:

Current Medications / Dose/ Frequency:

Please list all medications including strength dose and how many times you take each per day.

Preferred Pharmacy:

Preferred Pharmacy Number:

Drug Allergies / Reaction:

Please list all and include reaction. If you have no known allergies, please write "None".

Other Allergies:

Past Surgery:

Please list all and provide dates

Social History

Never smoked or have smoked less than 100 cigarettes per lifetime.
Current everyday smoker and have smoked more than 100 cigarettes per lifetime.
Current occasional smoker and have smoked more than 100 cigarettes per lifetime.
Former smoker and smoked more than 100 cigarettes per lifetime.
Heavy tobacco smoker and have smoked more than 10 cigarettes a day or the equivalent cigar or pipe smoke.
Light smoker and smokes less than 10 cigarettes per day or equivalent cigar or pipe smoke.

Select which one best describes your relationship with tobacco:

Marital Status

Occupation:

Do you drink alcohol

Type of alcohol

Beer
Wine
Liquor

Do you use recreation marijuana?

Do you use other recreational drugs?

List other recreational drugs used:

Have you ever used needles to inject drugs?

Have you ever taken someone else's drugs?

If cancer was selected what type:

Any other family history:

For any condition selected above, please provide details:

Which family member had what condition.

Upload an Image of your ID. (Driver's License, Military ID, Passport, Other):

Click or drag files to this area to upload. You can upload up to 4 files.

Please upload a cropped and clear image of your legal identification. Image size must be less than 10MB.

Upload an Image of the Front Side of Your Insurance Card:

Click or drag files to this area to upload. You can upload up to 4 files.

Please upload a cropped and clear picture/copy. Image size must be less than 10MB.

Upload an Image of the Back Side of Your Insurance Card:

Click or drag files to this area to upload. You can upload up to 4 files.

Please upload a cropped and clear picture/copy. Image size must be less than 10MB.

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