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Cross Road Medical Center
CONFIDENTIAL PATIENT INFORMATION
Responsibility: Office Manager CRMC FO 100
Revision Date: 08/07/14
Patient Name: *___________________________________ SSN: *______________________ Date of Birth:*___________________
Mailing Address: *_____________________________________ City: *_________________ State: *______ Zip:*_______________
Home Phone:*_______________________Cell :__________________________ Email:______________________________________
Physical Address:__________________________________________ Veteran*: Yes / No Primary Language: _______________
Is Cross Road your primary care provider? Yes/No If No, who is your primary care provider?__________________________
Ethnicity/Race: (Circle One) Hispanic/Latino Asian White Black/African American Native Hawaiian Other
Pacific Islander Alaska Native/American Indian More than 1 Race
Sexual Orientation: (Circle One) Lesbian, gay or homosexual Straight or heterosexual Bisexual Something else
Don’t know Choose not to disclose
Gender Identity: (Circle One) Male Female Transgender Male/Female-to-male Transgender Female/Male-to-Female
Other Choose not to disclose
*EMERGENCY CONTACT/RELEASE OF INFORMATION_________________________________________
You may discuss my medical needs or exchange information with the following:*___________________________________________
Name: _______________________ Phone: ______________________ Relationship to Patient: __________________
Name: ______________________ Phone: ______________________ Relationship to Patient: _________________
Name: ______________________ Phone: ______________________ Relationship to Patient: ________________
□ I do not want information released to anyone, including my spouse and/or other household members.
*COMPLETE IF PATIENT IS 0 -17 YEARS OF AGE:*______________________________________________
Parent/Legal Guardian:___________________________ Parent/Legal Guardian: ____________________________
Birthdate: ______ Address:_______________________ Birthdate:________ Address: _______________________
_______________________________________________ _________________________________________________
Home Phone: (_____)_____Cell Phone: (___)_______ Home Phone: (___)______ Cell Phone: (___)___________
Work Phone:(____)_________ Work Phone: (_____)_______
*INSURANCE INFORMATION-Indicate which is primary/secondary as well as cardholder’s DOB*
PRIMARY INSURANCE:
Name of Primary Insured/Cardholder:*______________________________________ Relationship to Patient:*_______________________
Patient ID #:*____________________________________________________ Birth Date of Primary Insured:*_______________________
Insurance Company:*________________________________ Group #:*_______________SSN of Primary Insured:*__________________
Insurance Address and Phone: *_______________________________________________________________________________________
SECONDARY INSURANCE:
Name of Primary Insured/Cardholder:_______________________________________Relationship to Patient:_________________________
Patient ID #:__________________________________________________________Birth Date of Primary Insured: ____________________
Insurance Company:________________________________ Group #:_______________ SSN of Primary Insured: ____________________
Insurance Address and Phone: ________________________________________________________________________________________
PLEASE FILL OUT OTHER (REVERSE) SIDE
Thank you for choosing us! As a Federally Qualified Health Center and in order to serve you
properly, we request you provide the following information. Required information is marked with *
Please print. All information will be kept confidential.