Patient Registration & Yearly Update Form

NEW PATIENTS: Please contact the office prior to filling out this form to confirm Insurance participation.

Date:

Patient Full Legal Name:

Patient Preferred Name:

DOB:

Gender Identity:

Address:

City:

Zip Code

Primary Contact Name

Primary Phone:

ETHNICITY:

Hispanic/Latino Non-Hispanic/Latino Unknown Declined to specify/Unknown

Language Preference:

Interpretation services may be available through your insurance.

RACE:

American Indian/Alaskan Native Native Hawaiian/Pacific Islander Asian White Black/African American Declined to Specify/Unknown Other

If other, please specify:

****Please fill out the information below with the parties that have legal custody or guardianship of the patient. If you have a partner that you would like to designate to have certain access, please fill out a designation form or provide a notarized OCFS-4940 form.****

PARENT OR LEGAL GUARDIAN #1

FULL NAME:

DOB

Home Address

SS No.

City

State

Zip Code

Cell Phone No.

Work Phone No.

Email address

Add Parent or Legal Guardian

PRIMARY INSURANCE COMPANY

PRIMARY INSURANCE COMPANY:

Policy or ID#

Group ID#

Subscriber/Policy Holder Name

Subscriber/Policy Holder Date of Birth

SECONDARY INSURANCE COMPANY

SECONDARY INSURANCE COMPANY:

Policy or ID#

Group ID#

Subscriber/Policy Holder Name

Subscriber/Policy Holder Date of Birth

Printed Name of parent/legal guardian/patient over 18:

The patient/guarantor is responsible for knowing the specifics of his/her insurance plan and following its procedures. We strongly advise checking with your insurance carrier prior to visiting a Specialty Doctor, obtaining x-rays, offsite lab work, hospital admissions and any other outside services. The patient/guarantor is responsible for communicating any of the above special needs to office staff and is ultimately responsible for payment for any services rendered. By signing below, you signify that you have read and understand the above statement and this office has permission to submit insurance claims on your behalf. I will be personally responsible for the balance in full until such information is provided. I understand that I am financially responsible for charges not covered or paid by this insurance. If my account is turned over to any attorney for collection, I will be responsible for attorney fees in the amount of thirty percent (30%) of the total debt plus court costs. Any outstanding balances are subject to service charges.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of parent/legal guardian/patient over 18

Date

Printed Name of parent/legal guardian/patient over 18:

Your information will be encrypted.