Patient InformationDate MM slash DD slash YYYY Name(Required) First Middle Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Date of Birth Month Day Year Age Sex Marital Status Social Security Number Email Phone Number(Required)Cell Number(Required)Work NumberEmployer Employer's Address Emergency Contact Relationship to patient Phone Number(Required)Cell NumberWork NumberReferring provider's name Phone NumberResponsible Party InformationSame As Patient? Yes No Name First Middle Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age Sex Marital Status Social Security Number Upload Photo ID(Required)Accepted file types: jpg, png, pdf, Max. file size: 300 MB.Relationship to patient Home Phone NumberWork NumberEmployer Employer's Address: Insurance InformationAre you covered by health insurance?YesNoIf no, please make payment arrangements with our business office.Primary Insurance Policy # Group # Policy Holder Name: Policy Holder Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Upload Insurance Card(Required)Accepted file types: jpg, png, pdf, Max. file size: 300 MB.Social Security Number Copay Secondary Insurance Policy # Group # Policy Holder Name: Policy Holder Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Social Security Number Copay Consent For Payment I hereby authorize payment of medical benefits billed to my insurance by Fulton Pharmacy, LLC dba Whitesell Home Medical Supply. I have listed all health insurance plans from which I may receive benefits. I hereby accept responsibility for payment for any service(s) provided to me that is not covered by my insurance. I agree to pay all copayments, coinsurance, and deductibles at the time services are rendered. I also accept responsibility for fees that exceed the payment made by my insurance if Fulton Pharmacy do not participate with my insurance. I hereby authorize Fulton Pharmacy, LLC dba Whitesell Home Medical Supply to use and/or disclose my health information which specifically identities me or which can reasonably be used to identify me to carry out my treatment, payment, and healthcare operations. I understand that while this consent is voluntary, if I refuse to sign the consent, Fulton Pharmacy, LLC dba Whitesell Home Medical Supply can refuse to treat me. I understand this authorization can only be revoked in writing. If I revoke my consent, such revocation will not affect any actions that Fulton Pharmacy, LLC dba Whitesell Home Medical Supply took before receiving my revocation. Signature of Patient or Patient's Representative Reset signature Signature locked. Reset to sign again Date Month Day Year Printed Name First Last Relationship of Representative to Patient
