NEW PATIENT INSURANCE

If you are a new patient, we would like you to complete our new patient
form and bring it with you to your appointment.
To complete this form, you must first print a copy. Please Click Here
to print this form.

Patient Name (Last First Middle):
________________________________________Date: ____/____/____

Home Address: _____________________________________________
City_______________________,Texas Zip Code __________________

SS# _____-_____-_____ Male Female Birthday ____/____/_____

Phone: Home (______) _______________________________________
Cell (______) _________________Work (______)__________________

Marital Status:
Minor Single Married Divorced Separated Widowed

Patient’s Employer: _________________________________________________________
Work (______)__________________
Address:__________________________________________________
City___________________State_____________Zip Code___________

Spouse: __________________________________________________ Employer: _________________________________________________
Home (_____)______________________________________________
Cell (______)_________________Work (______)__________________

If the patient is a student, name school/college: _________________________________________________________ City___________________State_____________Zip Code___________

Person to contact in case of emergency other then spouse: _________________________________________________________

Referring Physician (if any): _________________________________________________________

RESPONSIBLE PARTY

If insurance is not in patient’s name please fill out the next line

Name of insured:
_________________________________________________________ Relationship to patient: _______________________________________

SS# _____-_____-_____ Male Female Birthday ____/____/_____

Address:__________________________________________________
City___________________State_____________Zip Code___________

Employer:_________________________________________________
Home (____)___________________Work (_____)_________________

INSURANCE INFORMATION

Primary Insurance:___________________________________________
ID#____________________________Group # ____________________

Employer: _________________________________________________________ Work (_____)____________________

Secondary Insurance:_________________________________________
ID #_____________________________Group #___________________

AUTHORIZATION AND RELEASE

I authorize release of any information concerning my (or my child’s) health care, advice and treatment provided for the purpose of evaluating and administering claims for the insurance benefits. I hereby authorize payment of insurance benefits otherwise payable directly to Pedro M. Arguello, M.D., P.A. I have reviewed and sign a copy of “The Health Insurance Portability and Accountability Act of 1996“ (HIPAA)

_________________________________________________________
Signature of Patient or Guardian
Date_______/_______/________