Spokane Resource Group, PLLC
Patient Data Sheet
(Please Print)
Name: ________________________________________ Soc. Sec. No. ___________________
First
MI
Last
Address: __________________________________________ City: ______________________
State: ______________________ Zip Code: __________ Date of Birth: _________________
Primary Phone: ______________________________ May we leave a message? Y ( ) N ( )
Secondary Phone: ____________________________ May we leave a message? Y ( ) N ( )
Marital Status: ___________ Sex: M ( ) F ( )
Referred by (Name of Doctor) ________________________ Phone No. ____________________
Pharmacy Name _________________________________ Phone No.____________________
In an emergency, please notify ______________________ Phone No. ___________________
Primary Insurance Information
Insurance Name: ______________________________________________________________
Policy Number ________________________________________________________________
If YOU ARE INSURED UNDER A SPOUSE OR PARENT PLEASE PROVIDE THEIR
NAME AND DATE OF BIRTH BELOW:
______________________________________
__________________________________
Secondary Insurance Information
Insurance Name: ______________________________________________________________
Policy Number ________________________________________________________________
Assignments of Benefits
I hereby authorize payment directly to Spokane Resource Group of benefits due for services
provided. I understand I am financially obligated for charges not covered by this authorization. I
authorize release of information to the insurance provider in order to process this claim form. I
understand that there is a $50 charge for missed appointments unless advance notice has been given
at least 24 hours prior to the scheduled appointment.
___________________________________________________________________
Signature
Confidential
_______________________
Date
06//01/2012