LPFP Patient Information


First name:

Middle initial:

Last name:

Date of birth (MM/DD/YYYY):


Billing address
City, State, ZIP code
Home phone  
Cell phone  
Work phone  
Best way to contact you

Marital status

Spouse/significant other  
Emergency contact  
Relationship  
Emergency contact phone  
Race and ethnicity

 

Language preference
Email address
May we send test results to you by email?

 

May we send your billing statement by email?


Parent/Guardian (if patient is under 18)

Billing address
First name
Middle initial
Last name
Date of birth (MM/DD/YYYY)
Home phone
Cell phone
Work phone

Insurance Information

Insurance subscriber (main policy holder) name
Date of birth
(Fill out if we did NOT take a copy of your Insurance Card)
Insurance company
Company phone
Medical billing address
Member/subscriber number
Group/policy number
**Assignment of Insurance Benefits**
I hereby authorize Longs Peak Family Practice to recover from my insurance company, payment for any health service that is provided to me. I understand that I am financially RESPONSIBLE for ALL co-pays, co-insurance, deductibles, and non covered charges that is determined by my insurance company. I hereby authorize Longs Peak Family Practice to release all information necessary to secure such payments. A photocopy or electronic scan of this statement is to be considered as valid as the original.

 

Patient’s printed name
Relationship to patient
Patient or patient guardian please sign below (no periods or other punctuation allowed)

Leave this empty:

Longs Peak Family Practice https://LongsPeakFamilyPractice.com
Signature Certificate
Document name: LPFP Patient Information
Unique Document ID: cefcc4bbbb507f6428d4db226d1da6d15ed6fe5c
Timestamp Audit
2017-05-18 15:16:48 MSTLPFP Patient Information Uploaded by Chris Madden - lpfp@myupdox.com IP 50.194.156.193