Patient Registration Form

Patient Information

Legal First Name:

MI.

Last Name:

Address:

Home Phone:

Cell Phone:

Email:

Employer:

Work #:

Birth Date:

Social Security #:

Driveres License #:

If Other, Please specify

If Other, Please specify:

Referred By:

Primary Physician:

Responsible Party

Legal First Name:

MI.

Last Name:

Address:

Home Phone:

Cell Phone:

Email:

Birth Date:

Social Security #:

or Drivers License #:

Employer:

Work #:

Insurance Information

Primary Insurance Company:

Address:

ID Number:

Group Number:

Insured Name:

Insured DOB:

Insured Employer:

Relationship to patient:

Secondary Insurance Company:

Address:

ID Number:

Group Number:

Insured Name:

Insured DOB

Insured Employer:

Relationship to Patient::

Financial Policy:

I authorize the release of any information necessary to process claims. I request payment of benefits to John M. Enger D.P.M. I understand I am financially responsible for charges not covered by Insurance. I hereby authorize John M. Enger D.P.M and employees and/or agents to release all information, reports, and records if necessary for the purposes of treatment payment and healthcare operations, including a discussion of my medical condition to the insurance provider, rehabilitation provider, employer, hospitals, and doctors.
If your plan has a co-payment deductible and/or co-insurance you will be expected to pay your portion.

In the case of a divorce situation, the adult accompanying a minor patient is responsible for payment of services. Our office staff will not participate in any disputes which may arise with respect to financial liability due to legal custody agreements.

Payment is due at the time of service unless prior financial arrangements have been made with our business office. Any account balance is expected to be a paid in full and is your responsibility. Should it become necessary for the Community Foot Clinic to utilize the services of an outside collection agency, you may be held liable for collection agency fees and/or attorney fees.

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.

Patient / Responsible Party Signature:

Please fill up if patient is a minor child.

Date:

Your information will be encrypted.