Flagstaff Family Physicians, P.C -Robert Yee, M.D.

Available Forms

Alcohol Questionnaire- AUDIT -C *new patient form* Depression Health Questionnaire (PHQ-9) *new patient form* HIPAA *new patient form* Intake Questionnaire *new patient form* Medical Records Release *new patient form* Medicare Wellness Survey (Medicare Required) Patient Registration Form *new patient form* Payment Policy *new patient form* Physical Exam Form Required

Patient Registration Form new patient form

Patient Demographics Flagstaff Family Physicians,P.C.

Name & Permanent Mailing Address *

Best Number to use when contacting you *

Cell Phone Number *

Work Telephone Number

Home Telephone Number

Date of Birth *

Social Secuity *

Sex *

Marital Status *

Race *

Ethnicty *

Email *

Check here if you use a mail order pharmacy?

Mail Order Pharmcy

Local Pharmacy *

Emergency Contact Name & Number *

Relationship to Emergency Contact *

Insurance

Insurance Company Name *

Insurance Company Claims Mailing Address *

ID Number *

Group /Policy Number *

Please indicate your Group Name (if applicable)

Insurance Telephone Number *

Policy Holder's Name *

Policy Holder's Date of Birth *

Employer *

Name of Employer (if applicable) *

Secondary Insurance Information

Insurance Company Name & Claims Mailing Address *

*FFP does not bill secondary insurance companies. Please call your insurance company to set up a crossover. A crossover is the term used when primary insurance automatically sends claims to your secondary insurance company.

ID # / or policy Holder ID# *

Group or Policy # *

I authorize any applicable insurance payments to be sent to Flagstaff Family Physicians, P.C. I understand that coinsurance, deductibles and previous balances are due at the times services are rendered. I understand that if my account is turned over to a collection agency I will be responsible for a $50.00 charge in addition to the unpaid balance. I also understand that I will need to find another primary care provider and I will be released by Dr. Robert Yee's office.I understand that I will be given 30 days to locate a new provider.I understand that If I miss an appointment or cancel at the last minute or same day I will be responsible for a $50.00 fee.

Electronic Signature *

Date *

* Required field