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SOUTH CAROLINA CARDIOVASCULAR SURGERY CAROLINAS HOSPITAL SYSTEM

805 Pamplico Hwy, Medical Mall B, Ste. 230 Phone: 843-676-2760 Florence, S.C. 29505 Fax: 843-676-2762

PATIENT INFORMATION

Can we leave results or information on your home answering machine?  Yes   No Cell Voice Mail?  Yes   No

WELCOME! PLEASE PRINT CLEARLY PATIENT INFORMATION OFFICE USE ONLY Chart #   New Patient   Patient Update

PATIENT NAME  BIRTHDATE  AGE  GENDER

ADDRESS

CITY  STATE  ZIP  OCCUPATION

HOME PHONE #  CELL/BEEPER #

PATIENT EMPLOYER  WORK PHONE #

EMPLOYER ADDRESS  CITY  STATE  ZIP

MARITAL STATUS  SS#

LIST ALL FAMILY MEMBERS FIRST & LAST NAMES THAT ARE PATIENTS HERE

INSURANCE INFORMATION SELF PAY: YES NO GROUP#

I. PRIMARY MEDICAL INSURANCE CO  ID#

SUBSCRIBERS NAME  BIRTHDATE  SS#

SUBSCRIBERS ADDRESS IF DIFFERENT FROM PATIENT

RELATIONSHIP TO PATIENT

SUBSCRIBERS EMPLOYER

II. SECONDARY MEDICAL INSURANCE CO  ID#

SECONDARY SUBSCRIBERS NAME  BIRTHDATE  SS#

SECONDARY SUBSCRIBERS EMPLOYER

EMERGENCY NOTIFICATION INFORMATION

IN CASE OF EMERGENCY, PLEASE NOTIFY   RELATIONSHIP

HOME PHONE #  WORK PHONE #

INSURANCE CARD COPIED: YES    NO

Request for authorization for disclosure of Protected Health Information to a family member, friend or caregiver.

Authorized Person

Explanation:

Patient Signature

Signature of Authorized Person

Witness

Date

I authorize the release of any medical or other information necessary to process insurance claims, including Medicare or Medigap.       SignedDate I authorize payment of medical benefits directly to this practice for the services rendered, including Medicare and Medigap.       SignedDate

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