INFORMATION SHEET

 

                                                                                                Please circle one if applicable to this visit.

                                                                           Worker’s Compensation                    Motor Vehicle Accident

        1420 N 10th St.           Spearfish, SD 57783

        (605) 642-8414           Fax (605) 642-8618

 

PATIENT INFORMATION

Patient Last Name:                                                                    Maiden/Previous Last Name:                          

First Name:                                                       Middle Initial:    SSN:                                                                

Street Address:                                                              City:                                         State:                Zip:                

Mailing Address:                                                            City:                                         State:                Zip:                

Phone Number: (                      )                                   Birth date:                                 Single:              Married:         

RESPONSIBLE PARTY

Responsible Party Last Name:                                                   First Name:                                                    

Mailing Address:                                                            City:                                         State:                Zip:                

Phone Number: (                      )                                              

PATIENT EMPLOYMENT

Employer:                                                                                              Full-Time:                     Part-Time:                  

Employer Phone Number: (                   )                                                           Extension:                                           

INSURANCE-Please present Insurance, Medicare, Medicaid card(s) for copies.

Primary Insurance Company:                                                                                                                          

Policy Holder:                                                                Patient Relationship: Self          Spouse      Child      Other    

Policy Holder SSN:                                                                   Policy Holder Birth date:                                             

Policy/Contract/Member Number:                                                                                                                                 

Group Number:                                                 Effective Date:                                    

Secondary Insurance Company:                                                                                                                                  

Policy Holder:                                                                Patient Relationship: Self          Spouse      Child      Other    

Policy Holder SSN:                                                                   Policy Holder Birth date:                                             

Policy/Contract/Member Number:                                                                                                                                 

Group Number:                                                 Effective Date:                                    

 

Please circle below on How you heard about Queen City Medical Center.

Reference Sources:

     

      1-Yellow Pages            2-Newspaper                     3-Radio                        4-Word of Mouth        

                     5-Physician Referral                     6-Established Patient                      7-Other               8-Movie Theater

 

SIGNATURE:                                                                         DATE: