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Southern California Medical Gastroenterology Group, Inc
Endoscopy of Southern California
Patient Information Form
| o Male o Female |
Email: ________________________________________ |
| Last Name: _________________ |
First Name: __________________ |
M.I.: _______ |
Date of Birth:__ / __ / __ |
| Home Address: | ______________________________ |
City: _________________________ |
State: ____ |
Zip: ___________ |
| Mailing Address: ( if different )______________________ |
City: ___________________ |
State: ____ |
Zip: __________ |
| Home Phone: ( ___ ) _________________ |
Work Phone: ( ___ ) _________________ |
Cell #: ( ___ ) ________________ |
| Employer Name: ___________________________________________________ |
Occupation: _______________________ |
| Address: | _______________________________ |
City: ________________________ |
State: ____ |
Zip: __________ |
| Social Security #: _____________________ |
Driver's License #: _____________________ |
State of issue:________ |
| Spouse: _______________________________________________ |
Work Phone #: ___________________________ |
| Emergency Contact Name: _________________________________ |
Phone #: ____________________________ |
| Refered By: ____________________________________________ |
Phone #: __________________________________ |
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Race:
R1 American Indian
R2 Asian
R3 Black/African Amercan
R4 Hawaiian/Pacific Islander
R5 White
R9 Other
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Ethnicity
E1 Hispanic/Latino
E2 Non Hispanic/Non Latino
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INSURANCE INFORMATION
| Primary Insurance Name:
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Phone Number:
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| Insured 's Number:
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Group Number:
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| Name of Insured:
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Insured's SS #:
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Insured's Date of Birth #:
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| Secondary Insurance Name:
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Phone Number:
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| Insured 's Number:
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Group Number:
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| Name of Insured:
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Insured's SS #:
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Insured's Date of Birth #:
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I hereby assign to Southern California Medical Gastroenterology Group, Inc. and/or Endoscopy Center of
Southern California all money to which I am entitled for medical and/or surgical expense relative to the service rendered by
the Group. I hereby accept responsability for payment for any medically necessary or elective service(s) provided to me that
is not covered by my insurance. I understand I am financially responsible to said Group for charges not covered by this assignment. I further
agree in the event of non- payment, to bear the cost of collection, and/or court costs and reasonable legal fees should this be
required
I agree to pay all required copayments, coinsurance, and deductibles at the time the service is rendered in accordance with any health
plan rules.
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| Signature of Patient or guardian | date |
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