Demographic Form Test

Client Name (First, MI, Last)*

Client No.

Primary Street*

Primary City*

Primary State*

Primary Zip*

Address

Local same as Primary
Billing same as Primary

Local Street

Local City

Local State

Local Zip

Billing Street

Billing City

Billing State

Billing Zip

County of Legal Residence

(enter your county. please indicate if you are out of state or do not know the county.)

Home/Cell Phone

Work Phone

Email Address*

Where may we contact you?*

Primary Address
Local Address
Billing Address
Home Phone
Work Phone
Other Phone

Where may we leave a message?*

Home
Work
Other

Other Phone

Client Age*

DOB*

Month

Day

Year

Gender*

Soc. Sec. No.*

Marital Status*

If Other, Specify

Race*

Ethnicity*

Parent/Guardian/Custodian if Minor

Parent/Guardian/Custodian Phone

Emergency Contact*

Relationship

Emergency Contact Phone

Primary Language*

Client needs the assistance of an interpreter*

If yes, please specify

Client needs assistance with visualization of material or alternate format*

Advance Directive?*

How did you hear about us?*

Payers

Medicaid*

Medicaid No.

Medicare*

Medicare No.

Insured Cardholder Name

First Last

S.S. Number

Place of Employment

Insured DOB

Month

Day

Year

Primary Private Insurance

Insurance Plan No.

Group No.

Secondary Private Insurance

Insurance Plan No.

Group No.

Workers Comp
Veteran
Self

Other

EAP Involved/Eligible*

Company Name/Address/Phone

Are you human?

Payers

Serving the Van Wert County and surrounding communities for 40 years.

Van Wert Office

Paulding Office

Delphos Office