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Patient Center
Dr. Jeff
FAQ
Contact
814-235-2266
Home
Patient Center
Dr. Jeff
FAQ
Contact
814-235-2266
Patient Insurance Information
Subscriber Name
Birthdate
Phone Number
Address
Relationship to patient
Subscriber's Social Security Number
Employer Name
Work Phone Number
Insurance Company Name
Insurance Company Phone Number
Insured's ID #
Group #
Is patient covered by any other insurance?
Yes
No
Second Insurance Subscriber Name
Birthdate
Phone Number
Address
Relationship to patient
Subscriber's Social Security Number
Employer Name
Work Phone Number
Second Insurance Company Name
Second Insurance Company Phone Number
Insured's ID #
Group #
Insurance assignment, release of information, and authorization: (Please electronically sign by initialing below)
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