Tidewater Family Medical Care, PC

NEW PATIENT DEMOGRAPHICS

Today's Date * Title Last Name * First Name * MI Maiden Name Date of Birth * Age * Social Security # * Gender * Street Address * City * State * Zip Code * Home Phone # * Cell Phone # * Work Phone # * Check all that apply * Employer/ Company Name * Work Address * If married, what is your spouse's full legal name? Spouse's employer and work phone #?

Insurance Information

Name of PRIMARY medical insurance company? * Policy ID # * Subscriber's full legal name Subscriber's date of birth Patient's relationship to subscriber Name of SECONDARY medical insurance company? Policy ID # Subscriber's full legal name Subscriber's date of birth Patient's relationship to subscriber

In Case of Emergency

Name of person to contact in case of emergency * Relationship to patient * Best Contact Phone # * Alternate Phone #

Meaningful Use Requirements

The Health Information Technology for Economic and Clinical Health (HITECH) Act provides HHS with the authority to establish programs to improve health care quality, safety, and efficiency through the promotion of health information technology (HIT), including electronic health records and private and secure electronic health information exchange. Due to this legislation, we are required to ask you for the following information:

Please select your RACE * Please select your ETHNICITY * Please select your PRIMARY LANGUAGE *

Pharmacy Information

For your convenience, our physicians are able to electronically send your prescriptions to your pharmacy. Please provide your pharmacy information below:

Preferred Pharmacy * Pharmacy Phone # * Pharmacy Address or Intersection