Patient Name* First Name Last Name Date of Birth* Date Format: MM slash DD slash YYYY SS#*Gender*MaleFemaleAddress* Street Address Apt. No City State Zip Code Phone: Home*Phone: Work*Phone: Cell*E-Mail Address* Secret Question – What is the last 4 of your SS #*Preferred Language*Ethnicity* View/receive results/communications online through our patient portal WebView login information will be sent to your emailMarital Status*SingleMarriedDivorcedWidowedYour Employer*Who referred you to our office?*Emergency Contact Name*Emergency Contact Phone #*Relationship*I authorize PrimeCare of Novi and/or Dr. Kelly Krueger to release my medical information to:NamePhone NumberRelationship to PatientName of Insurance*Guarantor NameIf other than yourselfDate of Birth of the Insured SubscriberIf other than yourselfRelationship of Insured Subscriber to the PatientIf other than yourselfInsurance ID#*Name of Secondary InsuranceIf applicableSecondary Insurance ID #Group #*Guarantor NameIf other than yourselfNotice of Privacy Practices – Patient Acknowledgement Your name and signature below indicated that you have received/been offered a copy of PrimeCare of Novi’s/Dr Kelly Krueger Notice of Privacy Practices.* I AGREE to HIPAA Notice of Privacy Policy Click here to review* I AGREE to Payment Policy Click here to review* I authorize PrimeCare of Novi, PLLC/Dr Kelly Krueger to provide treatment to my legal dependent or myself. Patient/Guardian Initials*Please note that services you receive on the date of service may not be payable by your insurance carrier. This includes charges from our office and a separate Lab charge. You will be held responsible for payment if your insurance carrier does not cover these charges. *** Please avoid a potential $25 fee for appointments not cancelled before 24 hours of your scheduled time. *****Signature*Date* Date Format: MM slash DD slash YYYY
