Mesa Family Physicians    Patient Information (patient will receive the bill if all areas not fully completed) Last Name:   Home Phone: ( )  - First Name:   Cell Phone: ( )  - Address:   Work Phone: ( )  - City: State:   Date of Birth: Zip Code: Sex: ( m / f )   Social Security #: - - [   ] Single [   ] Married [   ] Other Occupation: Employer: Employer Address: Emergency Contact Name: (preferably someone who does not live with you) Emergency Contact Phone: ( )  - How did you hear about us?   [   ] Phonebook   [   ] Internet   [   ] Insurance provider list   [   ] Friend   [   ]Dr. Referral   [   ]Other Winter Visitors - Please complete summer address Address:   Approximate dates at this address: City: State:   From: To: Zip Code:   Phone: ( )  -   Insured/Guarantor Info (responsible party/insurance holder) Last Name:   Home Phone: ( )  - First Name:   Work Phone: ( )  - Address:   Date of Birth: City: State:   Social Security #: - - Zip Code: Sex: (m/f)   [   ] Single [   ] Married [   ] Other Employer Name:    Occupation: Address: Relationship to Patient: How do you intend to pay: [   ] cash [   ] check [   ] credit/debit card   Insurance Information We are happy to bill your primary insurance; however, we do NOT bill secondary insurances. All balances after your primary insurance pays are patient's responsibility. The patient understands that we expect payment from them and will NOT wait until their secondary pays them on past due balances.   Insurance company name: Insurance company address: Insurance company phone#: Policy number/member id/contract#: Group and/or Union: Group Name: Insured's Name: Insured's D.O.B Is this a work-related injury (done on the job?) [   ] yes [   ] no Is this a Motor Vehicle Accident? [   ] yes [   ] no Are you confident that you are assigned to one of our providers under an HMO or EPO plan? [   ] yes [   ] no List your PCP (primary care provider) if applicable: co pay amt:$   I hereby authorize my insurance company to pay Mesa Family Physicians directly for any and all medical or surgical treatments. I authorize release of any pertinent medical information from my chart to secure payment. A photo copy of this assignment is to be considered valid as an original. I understand that I am fully financially responsible for all charges, including, but not limited to co-payments, annual deductibles and unpaid claims.   I request that my chart remain in: [   ] Mesa [   ] Gilbert   Signed: Date:   PRINT FORM | CLOSE