Patient Demographic Form Patient Details

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Patient Demographic Form Contact Information

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This information will be used to contact you regarding your appointments, treatment concerns, and billing.

Patient Demographic Form Responsible Party's Information (Person financially responsible for this account)

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Patient Demographic Form Emergency Contact Information

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Patient Demographic Form Primary Insurance Details

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Patient Demographic Form Secondary Insurance Details

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Patient Demographic Form Referral Information

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Patient Demographic Form Signature

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I authorize the release of my medical records & diagnosis to any third-party payers. I authorize payment of medical beneifts to Yale Podiatry Group for services. I realize I am responsible for payment for services rendered to me. I authorize the disclosure of my medical history and/or diagnosis by my physician to health personnel when necessary for medical care. I permit a copy of this authorization to be used in place of the original.

(Please click below to sign)
(Your IP Address : IP:3.235.41.241 )

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