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Nancy Lefeber Hughes, M.D. Internal Medicine Associate 1515 Tremont - Galveston, Texas 77550 4097712040

Welcome to our office. Please provide us with the information requested below so that we may assist you in filing your health insurance forms. All information will be kept confidential.

Patient’s Name:

Date:

_______________

_________________________

____________

Sex:

_________________

Age:

_______

Birth date:

_________

Soc. Sec. #

_______________

Address:

____________________________________

________________________________

C i t y : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

State:

__________

Zip code:

_______________________

Home phone:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Cell phone:

_______________________

Spouse’s name (if child, Parent’s name): ____________________

_______________________

Name of Insurance plan:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Group # _________________________________________

Member ID#: _________________

Insurance holder’s name:

DOB:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_______________

Soc Sec. #

_____________________________

Relationship to Insured:

__________________

Address:

_____________________________________________________________________

C i t y : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

State: __________ Zip code:

_________________

Employer:

___________________________________

Occupation:

_______________________

Address:

______________________________________________________________________

City: __________________________

State: __________ Zip code:

____________________

Referring doctor:

________________________________________________________________

Reason for visit:

__________________________________________________________________

Family members who have been patients:

_____________________________________________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Emergency Contact:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Phone #:

_____________________________

Internal Medicine Associates will bill the insurer of patient, however patient agrees to pay for the reasonable costs of all services provided and will be responsible and agree to pay for any copay, deductable, or other charges not paid for by his insurance company.

________________________________________________________________________

(Patient Signature)

(Date)

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