ONLINE APPOINTMENT REQUEST FORM

Please complete all applicable fields, double check your entries, and choose "submit" to complete the form.

Patient Information

First Name

Middle Name

Last Name

Address

City

ST Zip

Phone

SSN#

Sex

M F

Spouse's date of birth (for insurance purposes) (mm/dd/yy)

/ /

Birthdate (mm/dd/yy)

/ /

Age

Marital Status

Employer		Occupation
Employer's address		Phone

Complete this section only if someone other than the patient is financially responsible

Responsible Party

Birthdate (mm/dd/yy)

/ /

Relationship to Patient

Mailing Address

City

ST Zip

Home Phone

Work Phone

SSN#

Employer		Occupation
Employer Address		Employer Phone

Insurance Information - Primary Provider
Company Name
Company Address
City	ST Zip	Insured Person's Name
Group #	Policy ID #	SSN#

Insurance Information - Secondary Provider
Company Name
Company Address
City	ST Zip	Insured Person's Name
Group #	Policy ID #	SSN#

In Case of Emergency, Please contact:
Name
Relationship to patient	Home phone	Work phone

How did you hear about Internal Medicine Group?

Referred by

Before submitting, please double check your entries!
(If the data is incomplete, we will ask you to fill out a new form when you arrive in person)

I hereby authorize medical treatment of the above named person and agree to be financially responsible for all charges for such treatment, including costs of collection and legal frees (if applicable). I hereby assign payments to Internal Medicine Group. I authorize Internal Medicine Group to release any medical information necessary to process my insurance claims. I agree that this authorization shall be valid until rescinded in writing or replaced by one of a later date.

I also agree that I have read our Notice of Privacy Practices (click the link to open the statement in a new window for your review)