Page 2 of 5

Personal Information

First Name
Middle Name
Last Name
Preferred Name
Gender
Date of Birth	Month Day Year
Social Security
Street Address
City
State
Zip Code
Cell Phone Number
Home Phone Number
Work Phone Number
Email Address
Contact Preference
Primary Language Spoken
Race
Martial Status
Spouse Name (If Applicable)
Occupation
Primary Care Physician
Current Employer
Emergency Contact Name
Emergency Contact Phone Number
Emergency Contact Relationship
Preferred Local Pharmacy
Pharmacy Phone Number

My Signature Confirms the Following

Information listed in my medical and financial file today is accurate and true to the best of my knowledge
I hereby grant permission to Dr. Eric Tiblier, P.A. to employ such medical, surgical, and X-ray procedures as my doctor may consider necessary in my diagnosis and treatment including "Medication Backfill".
I authorize the holder of medical or other information to release to my insurance carrier, governmental agency, or its intermediary any information needed for this or a related insurance claim.
I also confirm my insurance listed is effective for today's services
I understand to ensure accurate records, I will update any of this information when necessary
I authorize the release of medical or other information necessary to process this claim
I authorize payment of medical benefits to Dr. Eric Tiblier, P.A.
I have read Privacy Policies of this office
I have read and agree to the financial policy of this office and I agree to pay any charges incurred by me to Dr. Eric Tiblier, P.A.

Please sign your name below using your mouse:

(Use your mouse cursor to sign your name.
Click in the box to the right and hold down the mouse button
and drag your mouse cursor to sign your name.
Release the mouse button when you're done signing your name.)

Primary Insurance Information

Carrier
Guarantor's Full Name
Relationship to Patient
Guarantor Date of Birth	Month Day Year
Member ID Number
Group ID Number
Cardholder Street Address
Cardholder City
Cardholder State
Cardholder Zip Code
Cardholder Phone

Secondary Insurance Information

Carrier
Guarantor's Full Name
Relationship to Patient
Guarantor Date of Birth	Month Day Year
Cardholder's SSN
Group ID Number
Member ID Number

Page 2 of 5

Personal Information

My Signature Confirms the Following

Please sign your name below using your mouse:

Primary Insurance Information

Secondary Insurance Information

Submit Form