This office happened to put the form online.
I just left half of it blank.
No, you don't get my husband's social security number (I have my own insurance), or his boss's number.
My favorite, not on this form, is "Emergency Contact Who Does Not Live With You." I recognize that field. That's the one from the student loan forms. It's, "Person We Can Call If You Skip Town." No, thanks, but no.
You will note they ask for an emergency contact on this form, but don't ask for a PHONE NUMBER for the contact. I guess if you have a seizure or pass out, they don't care about who to call then, but if you are late with that co-pay... watch out!
These forms send a message to the patient that the doctor probably doesn't want to send.
"We don't care about you and who you are and why you are here, but we really, really, really want to be sure we are paid on time for every cent."
I was seeing a doctor who made you fill these out every quarter. I stopped going to that doctor. The fact that they didn't care (no form for that) when my medical status changed, but DID scan my driver's license every three months was just a little much.