Tricity Family Medicine & Urgent Care Clinic, PLLC

107 Hyannis Dr., Holly Spring, NC 27540
Ph: 919-363-8666 Fax: 919-363-8668

PATIENT DEMOGRAPHIC FORM

(THIS FORM IS TO BE UPDATED YEARLY OR WITH ANY INFORMATION CHANGES)

*PRIMARY INSURANCE INFORMATION

(We will make a copy of your Insurance Card. However, we do request that you fill in the information below)

RELEASE OF MEDICAL INFORMATION
I authorize Tri-City Family Medicine and Urgent Care Clinic, PLLC, to release the medical records concerning my son/daughter/self to any physician, hospital, or agency involved in the care of the patient listed.

ASSIGNMENT OF MEDICAL BENEFITS
I authorize my insurance carrier to assign all surgical and or medical benefits, if applicable, to Tri-City Family Medicine and Urgent Care Clinic, PLLC. I also authorize release of medical information necessary to process all medical insurance claims.

REFERRAL POLICY
I understand that it is my responsibility to obtain a referral through my primary care physician’s office if required by my insurance company. Failure to do so will result in charges being billed directly to myself.

I HAVE READ, UNDERSTAND, AND AGREE TO ABIDE BY THE ABOVE RELEASE OF MEDICAL INFORMATION. IT IS IMPORTANT TO PROVIDE US WITH ACCURATE INFORMATION REGARDING YOUR PRIMARY & SECONDARY INSURANCE. IF THE INFORMATION IS INACCURATE, YOU MAY BE HELD LIABLE FOR YOUR VISIT. BY SIGNING BELOW, YOU ARE INDICATING THAT THE INFORMATION ABOVE IS CORRRECT.

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