WPC  Z1ZhBL|dEbc7TD{yzglj1#v'_Hۜ='mfGDl9CᔋG}B' k ׺Γ{v^qN$/M/|'Nص^` <!J87HeexHdh]?և;'em3R\CgS!js{ܼ ~\Bp\wv`L &S4v 2 \aLqS/%CL?k, u!SS;z1* _@Ӻd\?"coᓂcBiPSd/7wz6ob}CY%/Y$t=X*󾏾cZm7]fBxE!^W_[K0? s(L75K-9kp6D0%]A|>=[#$ xbv7>KM UTUc#!jUN % 0( 0D 0DK K w@ 4   m L E% W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W W 0DY D3 B*  AQ > 0D 0DH NEC NURSES MAIN HALL0,,,,00(9 Z6Times New Roman RegularX($(3$ !  (3$ !  gggggggggA%:i>3|xU B a"  _kXXRecdBy򀀀  _P.C.N._Ԁ򀀀  Soap򀀀  Chart򀀀 RR Chart򀀀(3$ !  XXXX'dxd d`aVbWC<<CLevel 1Level 2Level 3Level 4Level 5(3$ !  ($$   1  !  _ Xl_8($`~f!* `E!*tt9l %%%% Q    TheFamilyHealthClinic,P.C. Q  PATIENTINFORMATIONFORM Q     Y      a      i AX)?dzE?AAX).dE.AAX).8dE.8AAX).8dE.8AAX).,dE.,AAX).,dE.,AkXXԀDATE#XdQXk#0 0# % %0q%#%#%AX)%.$dE%.$AAX)%.$dE%.$AAX)%.$dE%.$AAX)%.$dE%.$Aq%%q%%  %%%%AX)#dE#AAX)"dE"AAX)"dE"AkXXdQAX) $d$E $A߀PATIENTSLASTNAME0 " 0z " %" %0z %z %0*%%FIRSTNAME0*%*%02%%02%2%MIDDLENAME%% AX) xdE $A ( ЀSOCIALSECURITYNUMBER0 " 0z " %" %0z %z %0*%%DATEOFBIRTH02*%*%02%2%AGE7%% AX) xdE  $A    ЀSTREETADDRESS0  0" %%0z " %" %0z %z %0*%%CITY0*%*%0%%02%%STATE02%2%0%%0: %%ZIP*  : %: % AX) xdE  $A  ^  ЀMAILINGADDRESS(IfDifferentThanAbove)AX) xdEP  $A Q  ЀHOMEPHONE0 r 0r%r%0" %%0z " %" %AX)dEAAX)dEASEXAX)dEA߀MAX)dEAARITAX)YdEYAALAX)wdEwASTAAX)dEATUSAX)(dE(A`  z %z % Ѐ0  0r%%0r%r%0" %%0z " %" %0z %z %B kM#kB /#ԀB kF#kB w#ԀB kԀM#kB #ԀB kS#kB #ԀB kW#kB P#ԀB kD#kB #& %% AX) $dE $A߀EMPLOYEDBY0  0" %%0z " %" %0z %z %0*%%OCCUPATION0*%*%02%%02%2%0%%BUSINESSPHONE %% AX) xdEw $A x  ЀEMPLOYERSADDRESSAX) xdE $A  ЀSPOUSESNAME0  0" %%0z " %" %0z %z %0*%%OCCUPATION0*%*%02%%02%2%0%%BUSINESSPHONE"%% AX) xdE $A V ЀEMPLOYEDBY0  0" %%0z " %" %0z %z %0*%%EMPLOYERSADDRESSe*%*% AX) xdEH $A I ЀNEARESTFRIENDORRELATIVENOTLIVINGWITHYOU0  0%%RELATIONSHIP0%%0: %%TELEPHONEX: %: % AX) xdE $A ! @x x  XdQXkMEDICALINSURANCEINFORMATIONkXXdQԈ " AX)|\dE|\AAX) xdE $A M$    r PRIMARY 0 " 0z " %" %0z %z %0*%%0*%*% 0%%SECONDARY \%%% AX) xdEy $A z"& ЀPOLICYHOLDER0  0" %%0z " %" %0z %z %0*%%POLICYHOLDER1'*%*%  AX) xdE $A )  INSURANCECOMPANY0 " 0z " %" %GROUPNAME0*z %z %INSURANCECOMPANY0*%*%0%%GROUPNAME$*%% AX) xd7E $A X, ЀADDRESS0 r 0r%r%0" %%0z " %" %0z %z %0*%%ADDRESSg-*%*% AX) xd8EJ $A K/ ЀI.D.#0  0r%%GROUP#0" r%r%EFFECTIVEDATE0*" %" %I.D.#0*%*%0%%GROUP#0%%EFFECTIVEDATEZ0%% AX) xd8E $A 2 @ XdQXk RESPONSIBLEPARTYINFORMATION kXXdQԈ 3 AX) xd8E! $A !O5 @ PLEASECOMPLETETHEFOLLOWINGSECTION@ONLYIFSOMEONEOTHERTHANTHEPATIENTWILLBERESPONSIBLEFORTHEBILL.AX) xd7EA# $A B# 8 ЀNAMEAX) xd8E$ $A $"; ЀADDRESS0 r 0r%r%0" %%0z " %" %0z %z %0*%%CITY0*%*%0%%02%%STATE02%2%0%%0: %%ZIP$"<: %: % AX) xd8Ew& $A x& $> ЀHOMEPHONE0 r 0r%r%0" %%0z " %" %0z %z %0*%%RELATIONSHIPTOPATIENT0*%*%0%%SOCIALSECURITYNO.&/$?%% AX) xd8E( $A (%A ЀEMPLOYEDBY0  0" %%0z " %" %0z %z %0*%%EMPLOYERSADDRESS0*%*%0%%BUSINESSPHONE"(%B%% AX) xd8E) $A )V'D    AUTHORIZATION: IherebyauthorizeFamilyHealthClinictofurnishinformationtoinsurancecarriersconcerningmyillnessand *+(F treatments,andIherebyirrevocablyassigntotheClinicmedicalbenefitsorgovernmentbenefitsformedicalservicesrendered.IunderstandthatIamfinanciallyresponsibleforallchargesnotcoveredbyinsurance.!RESPONSIBLEPARTYSIGNATURE:AX) AdE .AA e. ,K B kL:\forms\ptinfo2