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D. DUANE BRAIN, PM PC PATIENT REGISTRATION FORM Office Use Only EHS Pt.# This information is confidential INSURANCE INFORMATION PATIENT INFORMATION Name Primary Ins. Co. Name Address Policyholder

How to fill out duane brann dpm pc

How to fill out Duane Brann DPM PC:

1. Start by obtaining the Duane Brann DPM PC form. This can usually be found on the official website of Duane Brann DPM PC or by visiting their office in person.
2. Gather all the necessary information and supporting documents required to fill out the form. This may include personal details, medical history, insurance information, and any relevant medical records or referral letters.
3. Carefully read through the instructions provided on the form. Make sure you understand all the questions and requirements before starting to fill out the form.
4. Begin filling out the form by providing your personal information such as your full name, date of birth, address, contact information, and social security number if required.
5. Proceed to provide your medical history, including any past surgeries, illnesses, or chronic conditions you may have. Be as thorough and accurate as possible to ensure proper medical care.
6. If applicable, provide your insurance information, including the name of your insurance provider, policy number, and any required authorization codes.
7. Answer any additional questions or sections on the form, such as emergency contact information or questions regarding your current symptoms or reasons for seeking medical care.
8. Double-check all the information filled out on the form for accuracy and completeness. Any errors or omissions could cause delays or complications in your medical treatment.
9. Once you are confident that the form is complete and accurate, sign and date it as required. If necessary, have a witness or healthcare professional also sign the form.

Who needs Duane Brann DPM PC:

1. Individuals who require specialized podiatric care or are experiencing foot or ankle problems may seek the services of Duane Brann DPM PC.
2. Patients who have been referred by their primary care physician or another healthcare professional for podiatric evaluation or treatment may need to visit Duane Brann DPM PC.
3. Individuals who have had previous podiatric treatment under the care of Duane Brann DPM PC may continue to seek their services for follow-up appointments, check-ups, or ongoing foot and ankle care.

Note: It is always advisable to consult with a healthcare professional or contact Duane Brann DPM PC directly for specific information regarding your individual needs and requirements.

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What is duane brann dpm pc?

Duane Brann DPM PC is a medical practice owned by Dr. Duane Brann specialized in podiatric medicine.

Who is required to file duane brann dpm pc?

Dr. Duane Brann or anyone designated by him as the responsible party for filing.

How to fill out duane brann dpm pc?

To fill out Duane Brann DPM PC, one must provide detailed financial information, patient data, and other relevant medical practice details.

What is the purpose of duane brann dpm pc?

The purpose of Duane Brann DPM PC is to report financial and operational information related to the medical practice.

What information must be reported on duane brann dpm pc?

Information such as revenue, expenses, patient visits, services provided, and any other relevant financial and operational data of the medical practice.