Pulmonary & Critical Care Consultants of Austin, LLP 1305 ...

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Pulmonary & Critical Care Consultants of Austin, LLP

1305 West 34th Street #400, Austin, TX 78705

(512) 459-6599, FAX (512) 459-8496

NAME: _________________________________________________________________________

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MI

PREFERRED NAME (if different from legal name):_______________________________________

M F

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ADDRESS____________________________________________ CITY____________________ ST______ ZIP CODE_____________

PRIMARY PHONE # ____________________________ Circle: home ? work - cell

SECONDARY PHONE #_________________________ Circle: home ? work ? cell

MAY WE LEAVE A MESSAGE? CIRCLE: Y - N

MAY WE LEAVE A MESSAGE? CIRCLE: Y - N

EMAIL __________________________________________________

DOB _____________ AGE ________

EMPLOYER________________________________ SOCIAL SECURITY #_____________________ MARITAL STATUS: M D S W P

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PHARMACY NAME _______________________________ LOCATION ____________________ PHONE ___________________

REFERRING PHYSICIAN ____________________________________________________________

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PRIMARY CARE PHYSICIAN

_____________________________________________________

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OTHER SPECIALISTS YOU SEE ________________________, ____________________________, ___________________________

*PRIMARY INSURANCE_______________________________________ Insured's Name __________________ DOB ________ Example: Humana Medicare PPO

SECONDARY INSURANCE____________________________________ Insured's Name __________________ DOB ________ Example: BCBS HMO

PERSON WE MAY CONTACT REGARDING YOUR MEDICAL CONDITION IN EMERGENCY

NAME: _______________________________ RELATIONSHIP: __________________

PRIMARY # _____________________ SECONDARY # ________________________

Circle: home ? work - cell

Circle: home ? work - cell

Persons we may inform or answer questions about your general medical conditions/diagnosis:

Contact ___________________________Relationship ________________Cell/Home _________________

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Contact ___________________________Relationship ________________Cell/Home _________________

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___________________________________________________ Signature of Patient or Insured

__________________________ Date

PRIVACY NOTICE: I AKNOWLEDGE I HAVE RECEIVED A COPY OF THE PRIVACY NOTICE FOR PULMONARY & CRITICAL CARE CONSULTANTS OF AUSTIN

___________________________________________________ Signature of Patient or Insured

__________________________ Date

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