Patient Name* First Name Last Name Date of Birth* MM slash DD slash YYYY SS#* Gender* Male Female Address* Street Address Apt. No City State Zip Code Phone: Home* Phone: Work* Phone: Cell* E-Mail Address* Secret Question – What is the last 4 of your SS #* Preferred Language* Ethnicity* WebView login information will be sent to your email View/receive results/communications online through our patient portal WebView login information will be sent to your emailMarital Status* Single Married Divorced Widowed Your Employer* Who referred you to our office?* Emergency Contact Name* Emergency Contact Phone #* Relationship* I authorize PrimeCare on Wixom and/or Dr. Kelly Krueger to release my medical information to:Name Phone Number Relationship to Patient Name of Insurance* Guarantor Name If other than yourselfDate of Birth of the Insured Subscriber If other than yourselfRelationship of Insured Subscriber to the Patient If other than yourselfInsurance ID#* Name of Secondary Insurance If applicableSecondary Insurance ID # Group #* Guarantor Name If other than yourselfNotice of Privacy Practices – Patient Acknowledgement Your name and signature below indicated that you have received/been offered a copy of PrimeCare on Wixom’s/Dr Kelly Krueger Notice of Privacy Practices.Click here to review* I AGREE to HIPAA Notice of Privacy Policy Click here to reviewClick here to review* I AGREE to Payment Policy Click here to review* I authorize PrimeCare on Wixom, PLLC/Dr Kelly Krueger to provide treatment to my legal dependent or myself. Patient/Guardian Initials* Please note that services you receive on the date of service may not be payable by your insurance carrier. This includes charges from our office and a separate Lab charge. You will be held responsible for payment if your insurance carrier does not cover these charges. *** Please avoid a potential $25 fee for appointments not cancelled before 24 hours of your scheduled time. *****Signature*Date* MM slash DD slash YYYY Δ
