Patient Information

Simplify the front office paperwork

This form can simplify paperwork for the front office. It provides sections for general information and responsible party details; suitable for adults and children. For patients with insurance, primary and/or secondary insurance information can also be noted.

The authorization section allows for assignment of benefits, "signature on file", general consent (Click on  Informed Consent Forms for more information), and information release. This authorization can also be photocopied and attached to an insurance claim form.

  • Patient information
  • Responsible party 
  • Accepted format for adults and children
  • Information for primary / secondary insurance coverage
  • Adapts to any office
  • Can implement service charge or "x" out if not applicable for your office
  • Provides insurance authorization
  • Provides general consent
  • "Signature on file"
C-114L Patient Information
$18.00 / 200 $34.00 / 400
$64.00 / 800 $120.00 / 1600



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