Medical Insurance Form




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Medical Benefits Questionnaire
Copy & Paste this form:  return options on bottom of page		 Date:
Part A - Patient  

Is the Patient also the Insured?  Yes  No

 Is there other insurance?  Yes   NO
Patient's Name:    DOB:
Patient's Address: Phone:
  Fax:
 City:                                State:  Zip:
e-mail address:
Patient Status:   ? Single  ? Married 
                              ? Other		 ? Employed
? Full or   ?  Part Time Student
Patient's Relationship to Insured:   ? Self   ? Spouse   ? Child   ? Other
   
Part B  
Insured's ID Number: Group Name/Number::
Employer's Name: Insurance Plan:
Doctor's Name: Doctor's Phone #:
Is the patient also the insured?      YES    NO Doctor's Fax:
         (Skip Part C below if Insured and Patient are Same)
Part C  
Insured's Name: Phone#:
Insured's Address: Fax:
City:                                          State: Zip:
   
Date of start of current:   ? Illness   or    ?  Injury
Diagnosis:  

Return to:
Fergus Affiliates, LLC dba ElderStore/BoomerStore & UroAnswers
6820 Meadowridge Court, Suite A-9, Alpharetta, GA  30005
Toll Free Phone:  888-833-8875
Fax:  678-845-0068
attach to e-mail:  insurance@elderstore.com

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