Patient Information Sheet

Margaret A. Smollen M.D., P.C.

Name: _______________________________________________________________
Address: _____________________________________________________________
City/State/Zip: _________________________________________________________
DOB: ________________________ SS#: ___________________________________
Home Phone #: _____________________ Employer: __________________________
Cell Phone #: ____________________ Work Phone #: _________________________
Marital Status: ___________________ (Single / Married / Widowed)
Emergency Contact: ______________________ Relationship __________________
Emergency Contact Phone #: _____________________________________________
Preferred Pharmacy: ________________________ City: ______________________
Pharmacy Phone #: ______________________
Referred By: ___________________________

Primary Insurance: _____________________________________________________

Policy ID #: ____________________________________________________________
Group #: ______________________________________________________________
Name of Policy Holder: ___________________________________________________
Policy Holders Address: __________________________________________________
City: ___________________State: ________ Zip Code: _____________
Policy Holder DOB: ______________________________________________________
Policy Holder Social Security Number: _______________________________________
Patientʼs Relationship to the Policy Holder: ____________________________________

Secondary Insurance: ___________________________________________________

Policy ID #: ____________________________________________________________
Group #: ______________________________________________________________
Name of Policy Holder: ___________________________________________________
Policy Holders Address: __________________________________________________
City: ___________________State: ________ Zip Code: _____________
Policy Holder DOB: ______________________________________________________
Policy Holder Social Security Number: _______________________________________
Patientʼs Relationship to the Policy Holder: ____________________________________

I verify the demographic information shown on this form is correct. I hereby authorize
Margaret A. Smollen M.D., P.C. to release necessary information to my insurance carrier to
process all claims and hereby assign to Margaret A. Smollen M.D., P.C. all payments for medical
services rendered.
I understand that I am responsible for all amounts not covered by insurance. I
further understand that co-pays and co-insurance are due at the time of service.

Signature: ____________________________________ Date: ____________________

319 E. Bloomington St.
Iowa City, IA. 52245.
Phone: 319-887-2229 Fax: 319-887-0906 Email: DrSmollen@Gmail.com