BAR Patient Registration

Patient Information

Please select:

New Patient Name Change Address Change Insurance Change

THIS SECTION MUST BE COMPLETED FOR ALL PATIENTS:

Today's Date:

Last Name:

First Name:

MI:

Date of Birth:

Age:

Sex:

Male Female

Preferred Language:

Race:

White

Native American

Asian

Black

Native Hawaiian

Other

Other:

Ethnic Group:

Hispanic/Latino Not Hispanic Unknown

Contact Information:

Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Work Phone:

Email:

PARENT, SPOUSE, OR RESPONSIBLE PARTY (if different from patient)

Last Name:

First Name:

MI:

Date of Birth:

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

INSURANCE COVERAGE - PRIMARY:

Insurance Co. Name:

Address of Claim Center:

City:

State:

Zip Code:

Name of Policy Holder (Insured):

Policy Holder (Insured) Date of Birth:

Policy #:

Group Name or #:

Policy Type:

HMO PPO

If patient is child, check relationship to insured:

Mother Father Other

If Other, please specify:

INSURANCE COVERAGE - SECONDARY:

Insurance Co. Name:

Address of Claim Center:

City:

State:

Zip Code:

Name of Policy Holder (Insured):

Policy Holder (Insured) Date of Birth:

Policy #:

Group Name or #:

Policy Type:

HMO PPO

If patient is child, check relationship to insured:

Mother Father Other

If Other, please specify:

Please upload a photo of your insurance card(s) and a photo ID along with this completed form. Thank you.

Please attach photos below:

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Please upload a file