New Patient Form

Demographics

Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr. Rev.

Address:
City:		State/ZipCode	WV KY OH PA TN VA

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Unknown Single Married Separated Divorced Widowed Child	Employer/School Name
Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev.

Address

City	State	ZipCode
	WV KY OH PA TN VA

Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:	None AARP ACS BENEFIT SERVICES ACTIVA BENEFITS AETNA Aetna Better Health of WV AMERIBEN AMERICAN BENEFIT CORP AMERICAN NETWORK INS CO AMERICAN RETIREMENT LIFE INSURANCE COMPANY APWU HEALTH PLAN ASSURED LIFE BAC BANKERS BANKERS FIDELITY BAS-WVA MANUFACTURING BCBS FREEDOM BLUE CLAIMS BENEFIT ASSISTANCE CORPORATION BENEFIT PLAN ADMINSTRATORS INC BOONE COUNTY BOARD OF EDUCATION BRICKSTREET MUTUAL INSURANCE COMPANY BRIDGESTONE AMERICAS INC CHAMPVA CHIPS CIGNA COEHA CONTINENTAL GENERAL INS CO CONTINENTAL LIFE INSURANCE COMPANY COVENTRY HEALTH & LIFE CO.-CARELINK DEPARTMENT OF VETERANS AFFAIRS FAMILY LIFE INSURANCE FAYETTE CONTINUOUS CARE FCBOE FIRST HEALTH LIFE (MEDCO) FREEDOM BLUE (BCBS) Freedom Blue PPO/ Highmark Senior Solutions GATEWAY HEALTH CLAIM SERVICE CENTER GEHA GERBER LIFE INSURANCE GOLDEN RULE INSURANCE COMPANY HARTFORD LIFE INSURANCE COMPANY HEALTH NET- VA CHOICE VACAA HEALTHSMART BENEFIT SOLUTIONS (CHARLESTON) HEALTHSMART BENEFITS SOLUTIONS, INC HealthSmart Casualty Claims-Black lung HIDDEN VALLEY-THE SUMMIT HIDDEN VALLEY NURSING HOME HIGHMARK BCBS Highmark Senior Solutions HILLTOP NURSING HOME HOSPICE HUMANA INFORMED KEY BENEFIT ADMINISTRATIONS LIONS CLUB MAIL HANDLERS BENEFIT PLAN Medcost Inc - 4Most MEDICARE WV - MEDICARE MEDICO MOLINA-MEDICAID MUTUAL OF OMAHA NALC HEALTH BENEFIT PLAN NATIONAL PARK SERVICE (NPS) NEW RIVER HEALTH OPERATING ENGINEERS LOCAL 99 PEIA (HEALTHSMART) PROVIDENT AMERICAN LIFE AND HEALTH INS. RAILROAD MEDICARE STANDARD LIFE AND ACCIDENT INS. CO. STATE FARM HEALTH INSURANCE STERLING INVESTORS LIFE INS. CO. STRATOSE (4MOST) TEAMSTERS- HEALTH AND WELFARE TRUST FUND THE EMPLOYEE BENEFIT SERVICE CENTER THE HEALTH PLAN THRIVENT FINANCIAL TRANSAMERICA TRICARE UFCW (KROGER) UMR UMWA 1950 AND 1974 UMWA 1993 UNICARE UNIFIED LIFE INSURANCE COMPANY UNITED AMERICAN INSURANCE COMPANY UNITED COMMERCIAL TRAVELERS OF AMERICA UNITED HEALTHCARE UNITED OF OMAHA LIFE INSURANCE COMPANY USAA WOODMEN OF THE WORLD WV Family Health WV Health Bridge WV Laborers Trust Fund
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary

Insurance Information

Insurance Name:	None AARP ACS BENEFIT SERVICES ACTIVA BENEFITS AETNA Aetna Better Health of WV AMERIBEN AMERICAN BENEFIT CORP AMERICAN NETWORK INS CO AMERICAN RETIREMENT LIFE INSURANCE COMPANY APWU HEALTH PLAN ASSURED LIFE BAC BANKERS BANKERS FIDELITY BAS-WVA MANUFACTURING BCBS FREEDOM BLUE CLAIMS BENEFIT ASSISTANCE CORPORATION BENEFIT PLAN ADMINSTRATORS INC BOONE COUNTY BOARD OF EDUCATION BRICKSTREET MUTUAL INSURANCE COMPANY BRIDGESTONE AMERICAS INC CHAMPVA CHIPS CIGNA COEHA CONTINENTAL GENERAL INS CO CONTINENTAL LIFE INSURANCE COMPANY COVENTRY HEALTH & LIFE CO.-CARELINK DEPARTMENT OF VETERANS AFFAIRS FAMILY LIFE INSURANCE FAYETTE CONTINUOUS CARE FCBOE FIRST HEALTH LIFE (MEDCO) FREEDOM BLUE (BCBS) Freedom Blue PPO/ Highmark Senior Solutions GATEWAY HEALTH CLAIM SERVICE CENTER GEHA GERBER LIFE INSURANCE GOLDEN RULE INSURANCE COMPANY HARTFORD LIFE INSURANCE COMPANY HEALTH NET- VA CHOICE VACAA HEALTHSMART BENEFIT SOLUTIONS (CHARLESTON) HEALTHSMART BENEFITS SOLUTIONS, INC HealthSmart Casualty Claims-Black lung HIDDEN VALLEY-THE SUMMIT HIDDEN VALLEY NURSING HOME HIGHMARK BCBS Highmark Senior Solutions HILLTOP NURSING HOME HOSPICE HUMANA INFORMED KEY BENEFIT ADMINISTRATIONS LIONS CLUB MAIL HANDLERS BENEFIT PLAN Medcost Inc - 4Most MEDICARE WV - MEDICARE MEDICO MOLINA-MEDICAID MUTUAL OF OMAHA NALC HEALTH BENEFIT PLAN NATIONAL PARK SERVICE (NPS) NEW RIVER HEALTH OPERATING ENGINEERS LOCAL 99 PEIA (HEALTHSMART) PROVIDENT AMERICAN LIFE AND HEALTH INS. RAILROAD MEDICARE STANDARD LIFE AND ACCIDENT INS. CO. STATE FARM HEALTH INSURANCE STERLING INVESTORS LIFE INS. CO. STRATOSE (4MOST) TEAMSTERS- HEALTH AND WELFARE TRUST FUND THE EMPLOYEE BENEFIT SERVICE CENTER THE HEALTH PLAN THRIVENT FINANCIAL TRANSAMERICA TRICARE UFCW (KROGER) UMR UMWA 1950 AND 1974 UMWA 1993 UNICARE UNIFIED LIFE INSURANCE COMPANY UNITED AMERICAN INSURANCE COMPANY UNITED COMMERCIAL TRAVELERS OF AMERICA UNITED HEALTHCARE UNITED OF OMAHA LIFE INSURANCE COMPANY USAA WOODMEN OF THE WORLD WV Family Health WV Health Bridge WV Laborers Trust Fund
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Tertiary

Insurance Information

Insurance Name:	None AARP ACS BENEFIT SERVICES ACTIVA BENEFITS AETNA Aetna Better Health of WV AMERIBEN AMERICAN BENEFIT CORP AMERICAN NETWORK INS CO AMERICAN RETIREMENT LIFE INSURANCE COMPANY APWU HEALTH PLAN ASSURED LIFE BAC BANKERS BANKERS FIDELITY BAS-WVA MANUFACTURING BCBS FREEDOM BLUE CLAIMS BENEFIT ASSISTANCE CORPORATION BENEFIT PLAN ADMINSTRATORS INC BOONE COUNTY BOARD OF EDUCATION BRICKSTREET MUTUAL INSURANCE COMPANY BRIDGESTONE AMERICAS INC CHAMPVA CHIPS CIGNA COEHA CONTINENTAL GENERAL INS CO CONTINENTAL LIFE INSURANCE COMPANY COVENTRY HEALTH & LIFE CO.-CARELINK DEPARTMENT OF VETERANS AFFAIRS FAMILY LIFE INSURANCE FAYETTE CONTINUOUS CARE FCBOE FIRST HEALTH LIFE (MEDCO) FREEDOM BLUE (BCBS) Freedom Blue PPO/ Highmark Senior Solutions GATEWAY HEALTH CLAIM SERVICE CENTER GEHA GERBER LIFE INSURANCE GOLDEN RULE INSURANCE COMPANY HARTFORD LIFE INSURANCE COMPANY HEALTH NET- VA CHOICE VACAA HEALTHSMART BENEFIT SOLUTIONS (CHARLESTON) HEALTHSMART BENEFITS SOLUTIONS, INC HealthSmart Casualty Claims-Black lung HIDDEN VALLEY-THE SUMMIT HIDDEN VALLEY NURSING HOME HIGHMARK BCBS Highmark Senior Solutions HILLTOP NURSING HOME HOSPICE HUMANA INFORMED KEY BENEFIT ADMINISTRATIONS LIONS CLUB MAIL HANDLERS BENEFIT PLAN Medcost Inc - 4Most MEDICARE WV - MEDICARE MEDICO MOLINA-MEDICAID MUTUAL OF OMAHA NALC HEALTH BENEFIT PLAN NATIONAL PARK SERVICE (NPS) NEW RIVER HEALTH OPERATING ENGINEERS LOCAL 99 PEIA (HEALTHSMART) PROVIDENT AMERICAN LIFE AND HEALTH INS. RAILROAD MEDICARE STANDARD LIFE AND ACCIDENT INS. CO. STATE FARM HEALTH INSURANCE STERLING INVESTORS LIFE INS. CO. STRATOSE (4MOST) TEAMSTERS- HEALTH AND WELFARE TRUST FUND THE EMPLOYEE BENEFIT SERVICE CENTER THE HEALTH PLAN THRIVENT FINANCIAL TRANSAMERICA TRICARE UFCW (KROGER) UMR UMWA 1950 AND 1974 UMWA 1993 UNICARE UNIFIED LIFE INSURANCE COMPANY UNITED AMERICAN INSURANCE COMPANY UNITED COMMERCIAL TRAVELERS OF AMERICA UNITED HEALTHCARE UNITED OF OMAHA LIFE INSURANCE COMPANY USAA WOODMEN OF THE WORLD WV Family Health WV Health Bridge WV Laborers Trust Fund
Insurance Plan:
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First, MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

PATIENT MEDICAL HISTORY: HAs, Arthritis, Asthma, Diabetes, HBP, Heart, Infl. Bowel Dz, Seizures, Thyroid

Injuries, Surgeries, Hospitalization

Please list all your medications:

Please list all the over-the-counter medications you take:

Vitamins:

Please list all eye drops:

Please list all Drug Allergies:

Primary Care Physcian:

Doesn't Remember Doesn't Have One None Keaveny Newell Petersen, Bruce Petersen, Millie White Other

FAMILY MEDICAL HISTORY: Diabetes, HBP, Heart Dz, Cancer, Athritis, Lupus, Kidney, Thyroid, Other

Hobbies:

Tobacco: No Yes Type: None Chewing Tobacco cigarettes How Long:

Alcohol:

No Yes Occasionally Socially

Illegal Drugs: No Yes Type: How Long:

Pregnant Or Nursing:

No Yes Unsure

Submit Data