Change of Insurance Location: Mercy Family Care Roscommon Patient Name: Patient Name: Date of Birth: Does this insurance replace your old insurance? Yes No   Name of Insurance that was terminated?   Date Terminated: Name of New Insurance: Is this insurance added to your other insurance?     Yes No Effective Date of New Insurance: The information below is needed for the person who the insurance is through: Name: Gender: Male Female Date of Birth: Address: Phone Number: Social Security #: Employer Employer's Address Employer's City Employer's State & Zipcode Employer's Phone Number Relationship of the Insurance Card Holder to the Patient Medicare Patients Only Do you have any insurance that should be billed before Medicare? Yes No Are you over age 65, still working and have coverage under your employer’s health plan? Yes No Is your spouse still working and has coverage for you under their employer’s health plan? Yes No Are you entitled to Medicare due to a disability? Yes No   Date of disability Are you entitled to Medicare due to End Stage Renal Disease? Yes No   Date of on set of your ESRD: Is this visit due to an Auto accident? Yes No   Date of accident:   Auto insurance:   By submitting this form, you indicate that you have completed all required fields with accurate information.