insurance demographic information form

Houston Methodist Wellness Services
INSURANCE DEMOGRAPHIC INFORMATION FORM
*Please provide a COPY front and back of your insurance card at the time of your appointment*
*Por favor proporcione una copia del frente y el dorso de la tarjeta del seguro medico en su primera cita*
Your name as it appears on insurance card:
Su nombre tal como aparece en la tarjeta de seguro:
First Name
Last Name
Primer nombre
Apellido
Current Mailing Address and Telephone:
Dirección actual y teléfono:
Street or P.O. Box
Calle o Apartado Postal
City
State
Zip Code
Telephone
Ciudad
Estado
Código postal
Teléfono
Gender:
Date of Birth
MM
DD
YYYY
F
M
Social Security Number
Sexo
Fecha de cumpleaños
Número de la seguro social
Insurance Information:
Información de Seguros
Insurance Carrier
Insurance P.O. Box Address
Compania Aseguradora
apartado postal de seguro
Policy Number/ Member ID
Group Number
Número de Póliza / identificación de miembro
Número de grupo
CPT Code: 90661
CPT Administration: 90471
Diagnosis Code: Z 23
The information cited on the form above is correct and complete. I understand that I am responsible for any portion of my bill not covered through my insurance plan, I authorize The Methodist Hospital physician Organization to act as an agent in obtaining payments from my insurance company. I authorize the
release of medical information to all parties involved in my care. I agree to allow copies of this authorization to be used in place of an original. I authorize the
use of “signature on file” to be used in insurance claim submissions which authorizes payment to be sent directly to the physician. I understand that I am
responsible for notifying the office of any pre-certification or referral requirements my insurance company may have.
Signature of patient or authorized agent
Firma del paciente o agente autorizado
Date
Fecha