Fillable Online Healthy TipsHouston Spine & Sports 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information in the 'Patient Information' section. Fill in your name, date of birth, age, and sex. Ensure that you provide a valid Texas Driver’s License and Insurance Card.
3. Complete your address details including city, state, and zip code. Don’t forget to include your home and mobile phone numbers.
4. Provide your employer's information along with the work phone number. Also, list an emergency contact person and their phone number.
5. In the 'Insured’s Information' section, fill out the policy holder’s name, relation to you, date of birth, and sex. If their address differs from yours, include that as well.
6. Next, enter your primary insurance details including policy number and group number. Repeat this for secondary insurance if applicable.
7. Review the 'Assignment of Insurance Benefits' and 'Authorization to Release Information' sections carefully before signing at the bottom of the form.

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