* indicates required field First Name * Last Name * Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year201820192020 Address * Apt # * City * State * Zip Code * Home Phone Cell Phone Email Marital Status * Married Single Divorced Widowed Employment * Full Time Part Time Retired Un-Employed Employer Employer Phone Primary Insurance Company Primary Insurance Co. Primary Insurance Policy # Primary Insurance Group # Name of Insured Secondary Insurance Company Secondary Insurance Co. Secondary Insurance Policy # Secondary Insurance Group # Name of Insured Are you allergic to any medications? Primary Care Physician Insurance Authorization * I Agree I Disagree I authorize the release of any medical information necessary to process my insurance claims. I also authorize and request payment of medical benefits directly to my physician. I agree that this authorization will cover all medical services rendered until such authorization is revoked by me. I agree that a photocopy of this form may be used in lieu of the original.