Oak Ridge OBGYN | Information Sheet

OB-GYN Associates of Oak ridge, P.C. | 988 Oak Ridge Turnpike, Physicians Plaza, Suite 140 | 865-483-7415

Patient Services
Information Sheet

Patient Information Sheet

Payment is due when services are rendered (includes co-payments and co-insurance). Click HERE to print out the payment policy form.

Please note that for your safety, you will be asked to provide your social security number upon arrival to the office rather then over the internet.

Please print out the Medical History Form and bring it with you to your first appointment.

You can also choose to print our patient information forms and bring them with you by clicking HERE.

Patient Last Name:
Patient First Name:
Patient Middle Name:
Patient Maiden Name:
Marital Status:	Single Married Widowed Divorced Seperated
Age:
Date of Birth (mm/dd/yyyy) :
Race:
Home Phone:
Cell Phone:
Street Address:
City, State Zipcode
Mailing Address (if different)
Email Address:
Patient's Employer:
Occupation (indicate if student) :
How Long Employed?
Business Phone:
Employer's Street Address:
City, State Zipcode
Spouse or Parent's Name:
Spouse or Parent's Date of Birth (mm/dd/yyyy) :
Spouse or Parent's Phone Number:
Spouse or Parent's Address:
City, State Zipcode
Spouse or Parent's Employer:
Spouse or Parent's Occupation (indicate is student) :
How Long Employed?
Business Phone:
Spouse or Parent's Employeer Street Address:
City, State Zipcode
Emergency Contact (not related) :
Emergency Contact's Phone Number:
Name of Nearest Relative:
Nearest Relative's Phone Number:
Drug Allergies:
Pharmacy Name:
Pharmacy Address:
City, State Zipcode:
Pharmacy Phone Number:
Referring Physician:
Referring Physician Address:
City, State Zipcode:
Referring Physician Phone Number:
Family Physician:
Family Physician Address:
City, State Zipcode
Family Physician Phone Number:
Financial Information
Primary Insurance
Insurance Name:
Filing Number:
Group Number:
Subscriber's Name:
Subscriber's Date of Birth (mm/dd/yyyy) :
Effective Date (mm/dd/yyyy) :
Patient's Relationship to Subscriber:
Secondary Insurance
Insurance Name:
Filing Number:
Group Number:
Subscriber's Name:
Subscriber's Date of Birth (mm/dd/yyyy) :
Effective Date (mm/dd/yyyy) :
Patient's Relationship to Subscriber:
All Professional Services rendered are charged to the patient. Necessary forms will be completed to help expedite Insurance carrier payments. However, the Patient is responsible for all fees, regardless of insurance coverage. Payment is due for services when rendered unless other aggangements have been made in advance.
INSURANCE AUTHORIZATION AND ASSIGNMENT
I HEREBY AUTHORIZE OB-GYN ASSOCIATES OF OAK RIDGE, P.C. TO FURNISH INFORMATION TO INSURANCE CARRIERS CONCERNING MY ILLNESS AND TREATMENTS AND I HEREBY ASSIGN TO THE PHYSICIAN(S) ALL PAYMENTS FOR MEDICAL SERVICES RENDERED TO MYSELF OR MY DEPENDENTS. I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY AMOUNT NOT COVERED BY MEDICAL INSURANCE.
Signed:
Date (mm/dd/yyyy) :