Carlos A Lozano MD PA

Available Forms

ACKNOWLEDGEMENT OF REVIEW OF NOTICE OF PRIVACY PRACTICES Additional Insurance Information Form Appointment Request Authorization to Release Medical Information New Patient Information Form Notice of Privacy Practices Prescription Refill Request Request of Medical Records

New Patient Information Form

Patient Demographics

Date

Patient Name *

First, Middle, Last, Suffix

Social Security Number *

Date of Birth *

Gender *

Male

Female

Home Address *

Address, City, State, Zip Code

DL#

State if not

Email Address

Home Phone

Mobile Phone

Work Phone

Employer Name & Address

If minor, Parent/Guardian Employer Address, City, State, Zip Code

Martial Status

Minor

Single

Married

Divorced

Widowed

Separated

Living Together

Spouse Name

If applicable

Spouse Employer/Phone

If Applicable

School/College, City & State

If Applicable

Preferred Language

English

Spanish

Race

White (Hispanic)

White

Black

Asian

Pacific Islander

Native American

Other

Ethnicity

Hispanic

Not Hispanic

Smoking Status

Smoker

Non-Smoker

Former Smoker

Alcohol Use

Never

Occasional

Daily

Referred By?

Emergency Contact & Phone

Responsible Party

If self, check here

If not self, fill out information below of Person Responsible

Name of Person Responsible

First, Middle and Last

Person Responsible a Patient?

Yes

Relationship to Patient

Person Responsible Address

Address, City, State, Zip Code

Same Address as patient

Person Responsible Email

Person Responsible Home Phone

Person Responsible Mobile Phone

Person Responsible DL#

State if not from TX

Person Responsible Date of Birth

Person Responsible Employer & Phone

Address, City, State, Zip Code, Phone

Insurance Information

Check below Insured

Self

Person Responsible

Other

If other fill in information below

Name of Insured

First, Middle, Last

Insured Relationship to Patient

Insured Date of Birth

Insured Social Security Number

Insured Employer,Address & Phone

Address, City, State, Zip Code

Insured Date Employed

Insurance Company

Policy #

Group #

Union/Local #

If Applicable

Insurance Address

Address, City, State, Zip Code

What is your Copay?

$ Amount

What is your Deductible?

$ Amount

How much Deductible Have You Used?

$ Amount

Ma. Annual Benefit?

$ Amount

Additional Insurance?

Yes

If Yes Please fill out Additional Insurance Form

By initialing, you agree to the statement below. *

I authorize release of any information concerning my (or my child's) health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I also hereby authorize payment of insurance benefits otherwise payable to me directly to the doctor.

Date

* Required field