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Patient Information

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Patient

First Name

Middle Name

Last Name

Date of Birth

Legal Sex

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Mobile Phone

Home Phone

Address

Address line 2

City

State

ZIP Code

Insurance Information
Uninsured patients are required to pay a down payment of $268 or $184 at the time of check-in.

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Insurance

Insurance Name

Member ID

Subscriber ID

Subscriber Name (First and Last Name)

Subscriber Date of Birth

Group Number

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Error: First name is required.

Error: Middle name is required.

Error: Last name is required.

Error: Name contains invalid characters.

Error: Spouse's last name is required.

Error: Spouse's last name first is required.

Error: Last name prefix is required.

Error: Spouse's last name prefix is required.

Error: Name suffix is required.

Error: Given name initials are required.

Error: Date of birth is required.

Error: Date of birth is invalid.

Error: Date of birth must be in the past.

Error: Legal sex is required.

Error: Email address is required.

Error: Email address is invalid.

Error: Home phone is required.

Error: Phone number is invalid.

Error: Mobile phone is required.

Error: Phone number is invalid.

Error: Work phone is required.

Error: Phone number is invalid.

Error: Address is required.

Error: City is required.

Error: County is required.

Error: Please enter a county.

Error: District is required.

Error: Please enter a district.

Error: House number is required.

Error: State is required.

Error: Please enter a state.

Error: ZIP code is required.

Error: Zip code is invalid.

Error: Country is required.

Error: Please enter a country.

Error: Social Security number is required.

Error: Social Security number is invalid. The correct format is ###-##-####.

Error: Social Security number is required.

Error: Insurance is required.

Error: Insurance name is required.

Error: Member ID is required.

Error: Subscriber ID is required.

Error: Subscriber name is required.

Error: Subscriber date of birth is required.

Error: Subscriber date of birth is invalid.

Error: Subscriber date of birth must be in the past.

Error: Group number is required.

Error: Must be exactly 4 characters.

Error: Cannot exceed 18 characters

Error: Cannot exceed 20 characters

Error: Cannot exceed 25 characters

Error: Cannot exceed 40 characters

Error: Cannot exceed 50 characters

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