NEW PATIENT INTAKE PACKET

2705 E 17th ST. Ammon, ID. 83406
Phone: 208.346.7500 / Fax: 208.346.7501

Patient Information

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Do you need an interpreter?
Marital Status *
 
Ethnicity *
 

Parent(s)/Guardian(s):
*The person completing the intake packet must be listed first*

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Are you the Insured Party?
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Are you the Insured Party?

Insurance Information:
**Accurate information is essential to providing timely care**

 Insurance Carrier
 Primary Insurance Carrier:Secondary Insurance Carrier:
Name:
Phone:
Policy Holder (PH):
Relationship of PH to you:
PH DOB:
PH SS#
Policy ID#:
Group#:

**Please bring insurance cards to 1st appointment**
(If you have more than two insurance carriers, please bring that information with you).

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