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Jonathan D. Schiele, D.C. 2919 Almost Rd., Suite 104, Boulder, CO 80301 (303) 4422126 Fax (303) 4440665 PATIENT INFORMATION/APPLICATION FOR CARE PLEASE PRINT. (The following information is needed
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How to fill out patient informationapplication for care
How to fill out patient information application for care:
01
Obtain the patient information application form from the healthcare provider or download it from their website.
02
Fill in the patient's personal information accurately, including their full name, date of birth, address, and contact details.
03
Provide the patient's insurance information, including the name of the insurance company, policy number, and any other relevant details.
04
Indicate the patient's medical history, including any pre-existing conditions, allergies, and current medications being taken.
05
If applicable, include emergency contact information for the patient, including the name, relationship, and contact details of the person to be contacted in case of an emergency.
06
Sign and date the patient information application form to confirm its accuracy and completeness.
07
Submit the completed form back to the healthcare provider as per their instructions.
Who needs patient information application for care:
01
Patients who are seeking medical services from a healthcare provider.
02
Individuals who are enrolling in a new healthcare plan or changing insurance providers.
03
Patients who are updating their personal or medical information with their healthcare provider.
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