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(Please Print) PATIENT INFORMATION Patients last name: First: Is this your legal name? Yes Middle: If not, what is your legal name? Mr. Mrs. (Former name): Single / Mar / Div / Sep / Did Birth date:
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How to fill out patient information - Bethany:
01
Start by gathering the necessary documents such as identification, insurance cards, and any relevant medical records.
02
Begin filling out the patient information form by providing Bethany's full name, date of birth, and contact information.
03
Next, include any relevant medical history, including current medications, allergies, and any chronic conditions Bethany may have.
04
Provide detailed information about Bethany's insurance coverage, including the policy number and contact information for the insurance company.
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If Bethany has any specific preferences or requirements, such as a preferred pharmacy or primary care physician, make sure to include that information.
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Lastly, review the filled-out form for any mistakes or missing information before submitting it.
Who needs patient information - Bethany:
01
The healthcare provider: Bethany's doctor, nurse, or any other medical professional involved in her care will need her patient information to properly assess and treat her.
02
The insurance company: Bethany's insurance company requires her patient information to verify her coverage and process any claims.
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The hospital or clinic: If Bethany visits a hospital or clinic, they will need her patient information to create a record of her visit and provide appropriate medical care.
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