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Patient Information * Required field Is This A New Patient To Our Practice Yes No First Name * Middle Last Name * Street Address * Apt/Suite City * State * -- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MI MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY Zip * DOB * Primary Phone Number * Secondary Phone Number Email Address * Preferred Contact Method * - Primary Phone Secondary Phone Email Does the patient have primary insurance coverage? Yes No Primary Insurance - (Insurance not listed) Aetna Elect Choice / Health Choices Aetna HMO, POS, QPOS, Open Access, Select Aetna Managed Choice Aetna Medicare HMO Aetna Medicare PPO Aetna National Advantage Program Aetna Open Choice PPO Aetna Whole Health AvMed AvMed Empower POS AvMed Engage HMO Blue Cross Blue Options (Network Blue) Blue Cross Blue Options (Network Blue) - ACA Exchange Plans Blue Cross Blue Shield - BH Employees Blue Cross Blue Shield Advantage 65 Blue Cross Blue Shield HMO - ACA Exchange Plans Blue Cross Blue Shield HMO (HOJ) Blue Cross Blue Shield Indemnity (PHS) Blue Cross Blue Shield myBlue (Duval County only) Blue Cross Blue Shield PPO (PPC) Blue Cross Medicare HMO (Except BlueMedicare Preferred HMO/Alignment Health) Blue Cross Medicare PPO (BlueMedicare Regional PPO) CIGNA HMO CIGNA PPO First Health PPO Great West Healthcare Medicare Medicare - Railroad Tricare Prime Tricare Select United AARP Medicare Complete / SecureHorizons/ Evercare/ UnitedHealthcare Dual Complete / WellMed HMO & PPO United Healthcare Community Plan United HMO United Open Access United POS United PPO Is the patient the subscriber? - Yes No Policy Number Member/Provider Phone Group Number Does the patient have secondary insurance coverage? Yes No Secondary Insurance - (Insurance not listed) Aetna Elect Choice / Health Choices Aetna HMO, POS, QPOS, Open Access, Select Aetna Managed Choice Aetna Medicare HMO Aetna Medicare PPO Aetna National Advantage Program Aetna Open Choice PPO Aetna Whole Health AvMed AvMed Empower POS AvMed Engage HMO Blue Cross Blue Options (Network Blue) Blue Cross Blue Options (Network Blue) - ACA Exchange Plans Blue Cross Blue Shield - BH Employees Blue Cross Blue Shield Advantage 65 Blue Cross Blue Shield HMO - ACA Exchange Plans Blue Cross Blue Shield HMO (HOJ) Blue Cross Blue Shield Indemnity (PHS) Blue Cross Blue Shield myBlue (Duval County only) Blue Cross Blue Shield PPO (PPC) Blue Cross Medicare HMO (Except BlueMedicare Preferred HMO/Alignment Health) Blue Cross Medicare PPO (BlueMedicare Regional PPO) CIGNA HMO CIGNA PPO First Health PPO Great West Healthcare Medicare Medicare - Railroad Tricare Prime Tricare Select United AARP Medicare Complete / SecureHorizons/ Evercare/ UnitedHealthcare Dual Complete / WellMed HMO & PPO United Healthcare Community Plan United HMO United Open Access United POS United PPO Is the patient the subscriber? - Yes No Policy Number Member/Provider Phone Group Number Physician Information Referring Physician Name * Referral Number Office Contact Name * Office Contact Phone * Office Fax Number Diagnosis * Have you had any of the following related to this diagnosis? (Check all that apply) Biospy Surgery Chemotherapy Radiation Additional Notes * Characters left (maximum 1000 characters)
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