Get the free Patient Information Form - US Department of Education

SECTION 3: GETTING THE HEALTH CARE YOU NEED PRACTICAL APPLICATION WORKSHEET Patient Information Form Directions: You are the patient. At home, fill out this form with your information. You do not

How to fill out patient information form

How to Fill Out Patient Information Form:

1. Start by writing your full name in the designated space on the form. Make sure to include your first name, middle initial (if applicable), and last name.
2. Provide your date of birth in the appropriate section. Write the month, day, and year of your birth in the specified format.
3. Indicate your gender by checking the appropriate box—male or female—on the patient information form.
4. Include your complete address. This should include your street address, city, state, and zip code.
5. Write down your primary phone number, ensuring that it is a valid and working contact number where you can be reached.
6. If you have an alternative or additional phone number, enter it in the space provided. This could be a mobile phone number or a secondary landline, for example.
7. List your emergency contact person's full name and relationship to you. Additionally, provide their phone number and any pertinent details, such as their availability or any medical conditions they should be aware of.
8. Specify your preferred pharmacy, if applicable. This includes the name, address, and contact information for the pharmacy where you regularly fill your prescriptions.
9. Provide your health insurance information, including the name of your insurance company, your policy or ID number, and any necessary group numbers.
10. Sign and date the form to verify its accuracy and completeness.

Who Needs a Patient Information Form:

1. Individuals visiting a healthcare provider for the first time usually need to fill out a patient information form. This ensures that the healthcare provider has accurate and up-to-date information about the patient.
2. Existing patients who experience changes in their personal details, such as a change in address, phone number, or insurance provider, may also need to update their patient information forms.
3. Patient information forms are required in various healthcare settings, including hospitals, clinics, doctor's offices, dental practices, and specialist centers. They serve as a crucial document for establishing a patient's medical history and contact information.

For pdfFiller’s FAQs

What is patient information form?

The patient information form is a document that collects relevant information about a patient's medical history, demographic details, and insurance information.

Who is required to file patient information form?

Healthcare providers, clinics, and hospitals are required to file patient information forms for each new patient.

How to fill out patient information form?

Patients or their caregivers can fill out the patient information form by providing accurate information about their medical history, current health conditions, and insurance details.

What is the purpose of patient information form?

The purpose of the patient information form is to ensure that healthcare providers have all necessary information to provide appropriate care and to bill insurance companies for services rendered.

What information must be reported on patient information form?

Information such as patient's name, date of birth, address, contact details, medical history, current medications, and insurance information must be reported on the patient information form.

How can I send patient information form to be eSigned by others?

When you're ready to share your patient information form, you can swiftly email it to others and receive the eSigned document back. You may send your PDF through email, fax, text message, or USPS mail, or you can notarize it online. All of this may be done without ever leaving your account.

Can I sign the patient information form electronically in Chrome?

You can. With pdfFiller, you get a strong e-signature solution built right into your Chrome browser. Using our addon, you may produce a legally enforceable eSignature by typing, sketching, or photographing it. Choose your preferred method and eSign in minutes.

How do I fill out patient information form on an Android device?

On Android, use the pdfFiller mobile app to finish your patient information form. Adding, editing, deleting text, signing, annotating, and more are all available with the app. All you need is a smartphone and internet.