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-0.007 Tc 0 Tw 436.56 395.64 Td
(Relationship:)Tj
ET
q
1 0 0 1 16.92 0 cm
467.28 393.24 86.76 -0.24 re
W n
467.28 393.24 108 -0.12 re
f*
Q
q
1 0 0 1 16.92 0 cm
1 g
358.08 388.44 108 -11.4 re
f*
Q
BT
-0.019 Tc 0.066 Tw 450.84 381.24 Td
(Phone #:)Tj
ET
q
1 0 0 1 16.92 0 cm
467.28 378.84 86.76 -0.24 re
W n
467.28 378.84 108 -0.12 re
f*
Q
q
1 0 0 1 16.92 0 cm
1 g
358.08 374.04 108 -11.4 re
f*
Q
BT
0 Tc 0.046 Tw 403.32 366.84 Td
(Emergency Contact 2:)Tj
ET
q
1 0 0 1 16.92 0 cm
467.28 364.44 86.76 -0.24 re
W n
467.28 364.44 108 -0.12 re
f*
Q
q
1 0 0 1 16.92 0 cm
1 g
358.08 359.64 108 -11.4 re
f*
Q
BT
-0.007 Tc 0 Tw 436.56 352.44 Td
(Relationship:)Tj
ET
q
1 0 0 1 16.92 0 cm
467.28 350.04 86.76 -0.24 re
W n
467.28 350.04 108 -0.12 re
f*
Q
q
1 0 0 1 16.92 0 cm
1 g
358.08 345.24 108 -11.4 re
f*
Q
BT
-0.019 Tc 0.066 Tw 450.84 338.04 Td
(Phone #:)Tj
ET
q
1 0 0 1 16.92 0 cm
467.28 335.64 86.76 -0.24 re
W n
467.28 335.64 108 -0.12 re
f*
Q
q
1 0 0 1 16.92 0 cm
7.56 303.72 0.12 -135.48 re
f*
Q
q
1 0 0 1 16.92 0 cm
7.56 303.84 4.8 -0.12 re
f*
Q
q
1 0 0 1 16.92 0 cm
121.56 303.84 444.24 -0.12 re
f*
Q
q
1 0 0 1 16.92 0 cm
565.68 303.84 0.12 -135.6 re
f*
Q
q
1 0 0 1 16.92 0 cm
7.68 168.36 558.12 -0.12 re
f*
Q
q
1 0 0 1 16.92 0 cm
1 g
7.68 303.72 558 -135.36 re
f*
Q
q
1 0 0 1 16.92 0 cm
1 g
12.48 308.16 109.08 -9 re
f*
Q
BT
0.005 Tc 0.041 Tw 30 300.96 Td
(Primary Insurance Information)Tj
ET
q
1 0 0 1 16.92 0 cm
7.56 654.72 0.12 -107.28 re
f*
Q
q
1 0 0 1 16.92 0 cm
7.56 654.84 4.8 -0.12 re
f*
Q
q
1 0 0 1 16.92 0 cm
204.12 654.84 361.68 -0.12 re
f*
Q
q
1 0 0 1 16.92 0 cm
565.68 654.84 0.12 -107.4 re
f*
Q
q
1 0 0 1 16.92 0 cm
7.68 547.56 558.12 -0.12 re
f*
Q
q
1 0 0 1 16.92 0 cm
1 g
7.68 654.72 558 -107.16 re
f*
Q
q
1 0 0 1 16.92 0 cm
1 g
12.48 659.16 191.64 -9 re
f*
Q
BT
-0.005 Tc 0.051 Tw 30 651.96 Td
(Responsible Party \(if someone other than the patient\))Tj
ET
/TouchUp_TextEdit MP
BT
0.013 Tc 0.032 Tw 24.6 690.72 Td
(First Name:)Tj
-0.008 Tc 0.054 Tw 58.8 -14.16 Td
(Policy Holder)Tj
ET
q
1 0 0 1 16.92 0 cm
1 g
52.8 683.64 9 -9 re
f*
Q
q
1 0 0 1 16.92 0 cm
0.12 w
52.68 683.76 9.24 -9.24 re
h
S
Q
BT
-0.004 Tc 0.051 Tw 83.4 663.96 Td
(Responsible Party)Tj
ET
q
1 0 0 1 16.92 0 cm
1 g
52.8 671.04 9 -9 re
f*
Q
q
1 0 0 1 16.92 0 cm
0.12 w
52.68 671.16 9.24 -9.24 re
h
S
Q
q
1 0 0 1 16.92 0 cm
1 g
0.6 w 1 j 1 J
q 1 0 0 1 29.76 556.08 cm
0 0 m
0 2.28 -1.92 4.08 -4.2 4.08 c
-6.48 4.08 -8.28 2.28 -8.28 0 c
-8.28 -2.28 -6.48 -4.2 -4.2 -4.2 c
-1.92 -4.2 0 -2.28 0 0 c
h
B*
Q
Q
BT
-0.005 Tc 49.8 552.72 Td
(Responsible Party is also a Policy Holder for Patient)Tj
ET
q
1 0 0 1 16.92 0 cm
1 g
0.6 w 1 j 1 J
q 1 0 0 1 239.76 556.08 cm
0 0 m
0 2.28 -1.92 4.08 -4.2 4.08 c
-6.48 4.08 -8.28 2.28 -8.28 0 c
-8.28 -2.28 -6.48 -4.2 -4.2 -4.2 c
-1.92 -4.2 0 -2.28 0 0 c
h
B*
Q
Q
BT
-0.003 Tc 0.049 Tw 259.8 552.72 Td
(Primary Insurance Policy Holder)Tj
ET
q
1 0 0 1 16.92 0 cm
1 g
0.6 w 1 j 1 J
q 1 0 0 1 389.76 556.08 cm
0 0 m
0 2.28 -1.92 4.08 -4.2 4.08 c
-6.48 4.08 -8.28 2.28 -8.28 0 c
-8.28 -2.28 -6.48 -4.2 -4.2 -4.2 c
-1.92 -4.2 0 -2.28 0 0 c
h
B*
Q
Q
q
1 0 0 1 16.92 0 cm
1 g
392.28 560.16 140.4 -9.6 re
f*
Q
BT
-0.009 Tc 0.056 Tw 409.2 552.72 Td
(Secondary Insurance Policy Holder)Tj
ET
q
1 0 0 1 16.92 0 cm
1 g
57.48 426.36 37.8 -9 re
f*
Q
BT
0.009 Tc 0.037 Tw 74.4 419.16 Td
(Section 2)Tj
-0.01 Tc -0.063 Tw 53.4 -15.24 Td
(Full Time)Tj
ET
q
1 0 0 1 16.92 0 cm
1 g
0.12 w 1 j 1 J
q 1 0 0 1 106.56 406.56 cm
0 0 m
0 2.52 -2.04 4.56 -4.56 4.56 c
-7.08 4.56 -9.12 2.52 -9.12 0 c
-9.12 -2.4 -7.08 -4.56 -4.56 -4.56 c
-2.04 -4.56 0 -2.4 0 0 c
h
B*
Q
Q
BT
-0.008 Tc -0.065 Tw 192.96 403.92 Td
(Part Time)Tj
ET
q
1 0 0 1 16.92 0 cm
1 g
0.12 w 1 j 1 J
q 1 0 0 1 171.72 406.56 cm
0 0 m
0 2.52 -2.04 4.56 -4.56 4.56 c
-7.08 4.56 -9.12 2.52 -9.12 0 c
-9.12 -2.4 -7.08 -4.56 -4.56 -4.56 c
-2.04 -4.56 0 -2.4 0 0 c
h
B*
Q
Q
BT
-0.014 Tc 0 Tw 258.12 403.92 Td
(Retired)Tj
ET
q
1 0 0 1 16.92 0 cm
1 g
0.12 w 1 j 1 J
q 1 0 0 1 236.88 406.56 cm
0 0 m
0 2.52 -2.04 4.56 -4.56 4.56 c
-7.08 4.56 -9.12 2.52 -9.12 0 c
-9.12 -2.4 -7.08 -4.56 -4.56 -4.56 c
-2.04 -4.56 0 -2.4 0 0 c
h
B*
Q
Q
q
1 0 0 1 16.92 0 cm
1 g
399.48 428.76 37.8 -9.6 re
f*
Q
BT
0.009 Tc 0.037 Tw 416.4 421.32 Td
(Section 3)Tj
0 Tc 0.047 Tw -115.92 102.84 Td
(Address 2:)Tj
ET
q
1 0 0 1 16.92 0 cm
327.48 522.36 223.2 -0.12 re
f*
Q
q
1 0 0 1 16.92 0 cm
1 g
327.48 531.36 223.2 -9 re
f*
Q
BT
0.011 Tc 0.034 Tw 235.68 508.92 Td
(State / Zip:)Tj
-0.057 Tc 0 Tw -205.08 -36.6 Td
(Sex:)Tj
0 Tc 0.045 Tw 200.52 0 Td
(Marital Status:)Tj
ET
q
1 0 0 1 16.92 0 cm
1 g
271.2 479.64 281.16 -9.36 re
f*
Q
q
1 0 0 1 16.92 0 cm
1 G
0.12 w 1 j 1 J
271.08 479.76 281.4 -9.6 re
h
S
Q
BT
-0.036 Tc 0 Tw 301.8 472.32 Td
(Married)Tj
ET
q
1 0 0 1 16.92 0 cm
1 g
0.12 w 1 j 1 J
q 1 0 0 1 280.56 474.96 cm
0 0 m
0 2.52 -2.04 4.56 -4.56 4.56 c
-7.08 4.56 -9.12 2.52 -9.12 0 c
-9.12 -2.4 -7.08 -4.56 -4.56 -4.56 c
-2.04 -4.56 0 -2.4 0 0 c
h
B*
Q
Q
BT
0 Tc 358.08 472.32 Td
(Single)Tj
ET
q
1 0 0 1 16.92 0 cm
1 g
0.12 w 1 j 1 J
q 1 0 0 1 336.84 474.96 cm
0 0 m
0 2.52 -2.04 4.56 -4.56 4.56 c
-7.08 4.56 -9.12 2.52 -9.12 0 c
-9.12 -2.4 -7.08 -4.56 -4.56 -4.56 c
-2.04 -4.56 0 -2.4 0 0 c
h
B*
Q
Q
BT
-0.019 Tc 414.36 472.32 Td
(Divorced)Tj
ET
q
1 0 0 1 16.92 0 cm
1 g
0.12 w 1 j 1 J
q 1 0 0 1 393.12 474.96 cm
0 0 m
0 2.52 -2.04 4.56 -4.56 4.56 c
-7.08 4.56 -9.12 2.52 -9.12 0 c
-9.12 -2.4 -7.08 -4.56 -4.56 -4.56 c
-2.04 -4.56 0 -2.4 0 0 c
h
B*
Q
Q
BT
-0.013 Tc 470.64 472.32 Td
(Separated)Tj
ET
q
1 0 0 1 16.92 0 cm
1 g
0.12 w 1 j 1 J
q 1 0 0 1 449.4 474.96 cm
0 0 m
0 2.52 -2.04 4.56 -4.56 4.56 c
-7.08 4.56 -9.12 2.52 -9.12 0 c
-9.12 -2.4 -7.08 -4.56 -4.56 -4.56 c
-2.04 -4.56 0 -2.4 0 0 c
h
B*
Q
Q
BT
0.331 Tc 526.92 472.32 Td
(Wi)Tj
-0.065 Tc 9.72 0 Td
(dowed)Tj
ET
q
1 0 0 1 16.92 0 cm
1 g
0.12 w 1 j 1 J
q 1 0 0 1 505.68 474.96 cm
0 0 m
0 2.52 -2.04 4.56 -4.56 4.56 c
-7.08 4.56 -9.12 2.52 -9.12 0 c
-9.12 -2.4 -7.08 -4.56 -4.56 -4.56 c
-2.04 -4.56 0 -2.4 0 0 c
h
B*
Q
Q
BT
0.023 Tc 30.6 436.32 Td
(E-mail:)Tj
ET
q
1 0 0 1 16.92 0 cm
42.48 434.16 219.6 -0.12 re
f*
Q
q
1 0 0 1 16.92 0 cm
1 g
42.48 443.76 219.6 -9.6 re
f*
Q
BT
-0.008 Tc 0.055 Tw 301.2 436.56 Td
(I would like to receive correspondences via e-mail.)Tj
ET
q
1 0 0 1 16.92 0 cm
1 g
270.6 443.64 9 -9 re
f*
Q
q
1 0 0 1 16.92 0 cm
0.12 w 1 j 1 J
270.48 443.76 9.24 -9.24 re
h
S
Q
q
1 0 0 1 16.92 0 cm
1 g
15.48 428.16 33 -4.8 re
f*
Q
q
1 0 0 1 16.92 0 cm
15.48 423.36 33 -0.12 re
f*
Q
q
1 0 0 1 16.92 0 cm
1 g
103.08 428.16 287.4 -4.8 re
f*
Q
q
1 0 0 1 16.92 0 cm
103.08 423.36 287.4 -0.12 re
f*
Q
BT
0.003 Tc 0 Tw 30.6 524.16 Td
(Address:)Tj
-0.011 Tc 0 -15.24 TD
(City:)Tj
ET
q
1 0 0 1 16.92 0 cm
33.48 506.76 181.2 -0.12 re
f*
Q
q
1 0 0 1 16.92 0 cm
1 g
33.48 516.36 181.2 -9.6 re
f*
Q
q
1 0 0 1 16.92 0 cm
49.08 522.36 225.6 -0.12 re
f*
Q
q
1 0 0 1 16.92 0 cm
1 g
49.08 531.36 225.6 -9 re
f*
Q
BT
-0.038 Tc 82.2 470.16 Td
(Male)Tj
ET
q
1 0 0 1 16.92 0 cm
1 g
0.12 w 1 j 1 J
q 1 0 0 1 60.96 472.8 cm
0 0 m
0 2.52 -2.04 4.56 -4.56 4.56 c
-7.08 4.56 -9.12 2.52 -9.12 0 c
-9.12 -2.4 -7.08 -4.56 -4.56 -4.56 c
-2.04 -4.56 0 -2.4 0 0 c
h
B*
Q
Q
BT
-0.007 Tc 82.2 460.92 Td
(Other)Tj
ET
q
1 0 0 1 16.92 0 cm
1 g
0.12 w 1 j 1 J
q 1 0 0 1 60.96 463.56 cm
0 0 m
0 2.52 -2.04 4.56 -4.56 4.56 c
-7.08 4.56 -9.12 2.52 -9.12 0 c
-9.12 -2.4 -7.08 -4.56 -4.56 -4.56 c
-2.04 -4.56 0 -2.4 0 0 c
h
B*
Q
Q
q
1 0 0 1 16.92 0 cm
0.12 w 1 j 1 J
q 1 0 0 1 60.6 463.56 cm
0 0 m
0 2.4 -1.92 4.2 -4.2 4.2 c
-6.6 4.2 -8.4 2.4 -8.4 0 c
-8.4 -2.28 -6.6 -4.2 -4.2 -4.2 c
-1.92 -4.2 0 -2.28 0 0 c
h
B*
Q
Q
BT
0.02 Tc 150.6 470.16 Td
(Female)Tj
ET
q
1 0 0 1 16.92 0 cm
1 g
0.12 w 1 j 1 J
q 1 0 0 1 129.36 472.8 cm
0 0 m
0 2.52 -2.04 4.56 -4.56 4.56 c
-7.08 4.56 -9.12 2.52 -9.12 0 c
-9.12 -2.4 -7.08 -4.56 -4.56 -4.56 c
-2.04 -4.56 0 -2.4 0 0 c
h
B*
Q
Q
q
1 0 0 1 16.92 0 cm
1 g
46.08 468.36 45.6 -9.6 re
f*
Q
BT
-0.003 Tc 0.05 Tw 30.6 454.92 Td
(Birth Date:)Tj
ET
q
1 0 0 1 16.92 0 cm
1 g
57.48 462.36 99 -9.6 re
f*
Q
q
1 0 0 1 16.92 0 cm
57.48 452.76 99 -0.12 re
f*
Q
q
1 0 0 1 16.92 0 cm
1 g
13.68 348.36 93 -9.6 re
f*
Q
BT
-0.01 Tc -0.063 Tw 110.4 384.72 Td
(Full Time)Tj
ET
q
1 0 0 1 16.92 0 cm
1 g
0.12 w 1 j 1 J
q 1 0 0 1 89.16 387.36 cm
0 0 m
0 2.52 -2.04 4.56 -4.56 4.56 c
-7.08 4.56 -9.12 2.52 -9.12 0 c
-9.12 -2.4 -7.08 -4.56 -4.56 -4.56 c
-2.04 -4.56 0 -2.4 0 0 c
h
B*
Q
Q
BT
-0.008 Tc -0.065 Tw 190.2 384.72 Td
(Part Time)Tj
ET
q
1 0 0 1 16.92 0 cm
1 g
0.12 w 1 j 1 J
q 1 0 0 1 168.96 387.36 cm
0 0 m
0 2.52 -2.04 4.56 -4.56 4.56 c
-7.08 4.56 -9.12 2.52 -9.12 0 c
-9.12 -2.4 -7.08 -4.56 -4.56 -4.56 c
-2.04 -4.56 0 -2.4 0 0 c
h
B*
Q
Q
BT
0.02 Tc 0.026 Tw 30.6 405.72 Td
(Employment Status:)Tj
0.01 Tc 0.036 Tw 0 -19.8 TD
(Student Status:)Tj
-0.013 Tc 0.06 Tw 0 -19.2 TD
(Medicaid ID:)Tj
0.009 Tc 0.036 Tw 164.4 0 Td
(Pref. Dentist:)Tj
ET
q
1 0 0 1 16.92 0 cm
228.48 364.56 124.8 -0.12 re
f*
Q
q
1 0 0 1 16.92 0 cm
1 g
228.48 374.16 124.8 -9.6 re
f*
Q
BT
0 Tc 0.046 Tw 30.6 344.16 Td
(Employer ID:)Tj
0.008 Tc 0.037 Tw 163.8 0 Td
(Pref. Pharmacy:)Tj
-0.023 Tc 0.069 Tw -163.8 -21 Td
(Carrier ID:)Tj
ET
q
1 0 0 1 16.92 0 cm
54.48 321.36 119.4 -0.12 re
f*
Q
q
1 0 0 1 16.92 0 cm
1 g
54.48 330.36 119.4 -9 re
f*
Q
BT
-0.003 Tc 0.049 Tw 194.4 323.16 Td
(Pref. Hyg.:)Tj
ET
q
1 0 0 1 16.92 0 cm
217.08 321.36 137.4 -0.12 re
f*
Q
q
1 0 0 1 16.92 0 cm
1 g
217.08 330.36 137.4 -9 re
f*
Q
q
1 0 0 1 16.92 0 cm
1 g
448.68 428.16 106.2 -4.8 re
f*
Q
q
1 0 0 1 16.92 0 cm
448.68 423.36 106.2 -0.12 re
f*
Q
q
1 0 0 1 16.92 0 cm
0.629 0.629 0.645 RG
0.6 w 1 j 1 J
q 1 0 0 1 356.88 413.76 cm
0 0 m
0 -93.6 l
S
Q
Q
BT
0 Tc 0.047 Tw 30.6 285.72 Td
(Name of Insured:)Tj
ET
q
1 0 0 1 16.92 0 cm
1 g
385.2 293.04 174.36 -9.36 re
f*
Q
q
1 0 0 1 16.92 0 cm
1 G
0.12 w 1 j 1 J
385.08 293.16 174.6 -9.6 re
h
S
Q
BT
0.006 Tc 0 Tw 415.8 285.72 Td
(Self)Tj
ET
q
1 0 0 1 16.92 0 cm
1 g
0.12 w 1 j 1 J
q 1 0 0 1 394.56 288.36 cm
0 0 m
0 2.52 -2.04 4.56 -4.56 4.56 c
-7.08 4.56 -9.12 2.52 -9.12 0 c
-9.12 -2.4 -7.08 -4.56 -4.56 -4.56 c
-2.04 -4.56 0 -2.4 0 0 c
h
B*
Q
Q
BT
0 Tc 459.36 285.72 Td
(Spouse)Tj
ET
q
1 0 0 1 16.92 0 cm
1 g
0.12 w 1 j 1 J
q 1 0 0 1 438.12 288.36 cm
0 0 m
0 2.52 -2.04 4.56 -4.56 4.56 c
-7.08 4.56 -9.12 2.52 -9.12 0 c
-9.12 -2.4 -7.08 -4.56 -4.56 -4.56 c
-2.04 -4.56 0 -2.4 0 0 c
h
B*
Q
Q
BT
-0.012 Tc 502.92 285.72 Td
(Child)Tj
ET
q
1 0 0 1 16.92 0 cm
1 g
0.12 w 1 j 1 J
q 1 0 0 1 481.68 288.36 cm
0 0 m
0 2.52 -2.04 4.56 -4.56 4.56 c
-7.08 4.56 -9.12 2.52 -9.12 0 c
-9.12 -2.4 -7.08 -4.56 -4.56 -4.56 c
-2.04 -4.56 0 -2.4 0 0 c
h
B*
Q
Q
BT
-0.007 Tc 546.48 285.72 Td
(Other)Tj
ET
q
1 0 0 1 16.92 0 cm
1 g
0.12 w 1 j 1 J
q 1 0 0 1 525.24 288.36 cm
0 0 m
0 2.52 -2.04 4.56 -4.56 4.56 c
-7.08 4.56 -9.12 2.52 -9.12 0 c
-9.12 -2.4 -7.08 -4.56 -4.56 -4.56 c
-2.04 -4.56 0 -2.4 0 0 c
h
B*
Q
Q
q
1 0 0 1 16.92 0 cm
1 g
84.48 291.36 213 -9.6 re
f*
Q
q
1 0 0 1 16.92 0 cm
84.48 281.76 213 -0.12 re
f*
Q
q
1 0 0 1 16.92 0 cm
1 g
431.88 612.24 123 -9.6 re
f*
Q
q
1 0 0 1 16.92 0 cm
431.88 602.64 123 -0.12 re
f*
Q
q
1 0 0 1 16.92 0 cm
1 g
428.88 596.64 126 -9.6 re
f*
Q
q
1 0 0 1 16.92 0 cm
428.88 587.04 126 -0.12 re
f*
Q
q
1 0 0 1 16.92 0 cm
1 g
14.28 644.04 41.4 -9.6 re
f*
Q
BT
0.013 Tc 0.032 Tw 31.2 636.6 Td
(First Name:)Tj
ET
q
1 0 0 1 16.92 0 cm
49.08 618.84 228 -0.12 re
f*
Q
BT
0 Tc 0.047 Tw 298.68 621 Td
(Address 2:)Tj
ET
q
1 0 0 1 16.92 0 cm
324.48 618.84 222.6 -0.12 re
f*
Q
q
1 0 0 1 16.92 0 cm
1 g
14.28 644.04 41.4 -9.6 re
f*
Q
BT
0.013 Tc 0.032 Tw 31.2 636.6 Td
(First Name:)Tj
ET
q
1 0 0 1 16.92 0 cm
1 g
14.28 628.44 34.2 -9.6 re
f*
Q
BT
0.003 Tc 0 Tw 31.2 621 Td
(Address:)Tj
ET
q
1 0 0 1 16.92 0 cm
1 g
67.08 596.64 96.6 -9.6 re
f*
Q
q
1 0 0 1 16.92 0 cm
67.08 587.04 96.6 -0.12 re
f*
Q
BT
-0.006 Tc 0.052 Tw 31.2 589.2 Td
(Home Phone:)Tj
ET
q
1 0 0 1 16.92 0 cm
1 g
58.08 581.04 98.4 -9.6 re
f*
Q
q
1 0 0 1 16.92 0 cm
58.08 571.44 98.4 -0.12 re
f*
Q
BT
-0.003 Tc 0.05 Tw 30.6 573.6 Td
(Birth Date:)Tj
-0.009 Tc 0.056 Tw 340.2 -0.6 Td
(Drivers Lic:)Tj
ET
q
1 0 0 1 16.92 0 cm
398.88 570.24 134.4 -0.12 re
f*
Q
q
1 0 0 1 16.92 0 cm
1 g
217.68 581.04 113.4 -9.6 re
f*
Q
q
1 0 0 1 16.92 0 cm
217.68 571.44 113.4 -0.12 re
f*
Q
BT
0.022 Tc 0.024 Tw 198 573.6 Td
(Soc Sec:)Tj
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