Form 4180 for Allentown Pennsylvania 2012-2024

Form 4180 for Allentown Pennsylvania: What You Should Know

Give the patient's Full Social Security Number and Date of Birth. • If the patient already has this information recorded, or if the patient is unable to provide this information, state this fact. • State a complete, accurate and complete name of patient(s) and provide additional personal identification information, such as: Social Security Number for the patient(s) Medical Records of patient(s), if available. Dec 16, 2024 — How To Fill In the “Physician's Signature” Line of the Patient Information and Provide All The Required Information On the Medical Records Authorization Form. ◇ Patient Information • Enter the patient's name, date of birth, and home address and telephone number. • Check the box to indicate that this patient is an individual. • Enter the physician's name • This patient is not a student and may need permission to see/see a specialist/doctor. • Indicate whether medical records relating to this patient have ever been released, and whether the patient has ever been a resident in another state for less than six months. • Check the box to indicate if the patient has ever been on an active disability list. • Check the box to indicate whether the patient was prescribed medication by a doctor or other health-care provider. This patient is not a student and may need permission to see/see a specialist/doctor. • Include the patient's date of birth, if available. ◇ Insurance Information • Complete or enter coverage information, such as: Insurance Name of the health insurance provider Insurance Type • If there are more than one insurance provider, state which one the patient is insured with. • Enter if the patient is a  self-insured health plan, a State Children's Health Insurance Program (SHIP) applicant, or an enrolled individual in Medicaid, CHIP, Medicare, or any state health program. • Enter insurance information that covers the patient and, if additional information is available, provide this information. • Check the box to indicate if the patient is covered under any other type of health insurance.  • State whether the patient is enrolled in any health plan. • Indicate if the patient is currently on public assistance. • Enter insurance information that covers the patient and, if additional information is available, provide this information.

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