All information provided is protected under the Health Insurance Portability and Accountability Act (HIPAA).

Patient Information

Full Name

Date of Birth (MM/DD/YYYY):

Social Security Number (Last 4 Digits):

Phone

Email Address:

Address

Address Line 1

City

State / Province / Region

Postal Code

Emergency Contact

Name

Relationship to Patient:

Phone Number:

Insurance Information

Primary Insurance Provider:

Member ID / Policy Number:

Group Number:

Policy Holder Name:

Policy Holder’s DOB (MM/DD/YYYY):

Relationship to Patient:

Insurance Phone Number (on card):

Please attach a copy of your insurance card (front and back).

Click or drag files to this area to upload. You can upload up to 2 files.

Secondary Insurance (if applicable)

Insurance Provider:

Member ID / Policy Number:

Group Number:

Policy Holder Name:

Policy Holder’s DOB (MM/DD/YYYY):

Social to Number

Relationship to Patient:

Acknowledgment and Consent

By signing below, I acknowledge that the above information is accurate to the best of my knowledge. I consent to the release of necessary medical information to my insurance company for billing purposes and understand that this form will be stored and transmitted securely in accordance with HIPAA regulations.

Signature of Patient or Guardian:

Clear Signature

Who Referred you to us:

Date (MM/DD/YYYY):

All information provided is protected under the Health Insurance Portability and Accountability Act (HIPAA).

Patient Information

Emergency Contact

Insurance Information

Secondary Insurance (if applicable)

Acknowledgment and Consent

Contact Details

Dallas Location

5787 S Hampton Rd Ste 108, Dallas, TX 75232-6335, US

(214) 272-7322

Houston Location

12941 North Fwy, Suite 224 Houston, TX 77060

(713) 878-9070

info@liahwellnesscenter.com

8 AM - 5 PM , Monday - Saturday

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