<p> INFORMATION CHANGE FORM Chart #______</p><p>I understand that Barg Family Clinic files my insurance as a courtesy to patients. I also understand that if I do not complete this insurance change form with all the information needed, I am responsible for today’s visit at the time of service.</p><p>RESPONSIBLE PARTY INFORMATION ***** (IF OTHER THAN PATIENT)***** First Name______M.I.______Last Name______Address______Telephone ______City______State______Zip______</p><p>PATIENT INFORMATION First Name______M.I.______Last Name______Address______Telephone______City______State______Zip______DOB______Race ______Sex______Marital Status: S M W D SSN______Cell phone Number______Spouse Name ______Employer______Employer Telephone______</p><p>INSURANCE INFORMATION Primary Insurance Co______Effective Date______Address______Telephone______City______State______Zip______Group #______Policy/ID #______Insured’s Name______Relationship Between Patient and Policy Holder______Insured’s DOB______Insured’s SSN______Insured’s Employer______Insured’s Address______Insured’s Telephone______</p><p>Secondary Insurance Co______Effective Date______Address______Telephone______City______State______Zip______Group #______Policy/ID #______Insured’s Name______Relationship Between Patient and Policy Holder______Insured’s DOB______Insured’s SSN______Insured’s Employer______Insured’s Address______Insured’s Telephone______</p><p>Tertiary Insurance Co______Effective Date______Address______Telephone______City______State______Zip______Group #______Policy/ID #______Insured’s Name______Relationship Between Patient and Policy Holder______Insured’s DOB______Insured’s SSN______Insured’s Employer______Insured’s Address______Insured’s Telephone______I hereby authorize this clinic to furnish my designated insurance carrier all information concerning my illness or injury. I also authorize benefits under claims filed to be made payable to Arkansas Family Care Network, P.A. I understand that I am responsible, financially, to this clinic for charges not covered in this authorization.</p><p>I hereby give consent to medical treatment, including emergency measures or hospitalization in the event that I am unable, because of extreme illness, injury or mental impairment to make an informed decision regarding treatment. I understand that the decision to treat will be based on my medical history and the circumstances associated with this event, and that the safest treatment methods will be used.</p><p>______Date______Signature of Patient or of the Responsible Party</p><p>I, ______, HEREBY CONSENT TO ALLOW THE FOLLOWING PERSON(S) ACCESS TO INFORMATION ON MY ACCOUNT THAT WOULD OTHERWISE BE CONSIDERED PROTECTED HEALTH INFORMATION: ______</p>