Betty H Yao, MD APC

New Patient Enrollment

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Full Name * Date of Birth * Social Security Number * Address * Home phone: Cell Phone: * Work Phone: Martial Status * Email * Primary Insurance * Subscriber name * Relationship to Suscriber * Suscriber Social Security Number * Suscriber Date of Birth * Member ID Number * Group Number * Secondary Insurance Relationship to Suscriber Suscriber Date of Birth Member ID Number Group ID Emergency Contact-Relationship, Name and Phone Number * Signature * Today's Date * Race/Ethnicity: *