Patient Registration Form

Today’s Date:

PCP:

Patient Information

Patient's Name

Nick Name:

Birth Date:

Sex:

Male Female

Sibling's Name

Sibling's Birth Date

Add more

Mother's Name:

Primary Number:

Type of Phone Number:

Cell Home Work

Alternate Number:

Type of Phone Number:

Cell Home Work

Email:

Father’s Name:

Primary Number:

Type of Phone Number:

Cell Home Work

Alternate Number:

Type of Phone Number:

Cell Home Work

Email:

Emergency Contact Name:

Relationship to Patient:

Emergency Contact Number:

GUARANTOR INFORMATION (PERSON RESPONSIBLE FOR THE BILL)

Guarantor Name:

Relationship to Patient:

Birth Date:

Address:

Primary Contact Number:

PRIMARY SUBSCRIBER INFORMATION (PERSON WHO HOLDS THE INSURANCE POLICY)

Primary Subscriber’s Name (If different from above):

Birth Date:

Social Security Number:

Sex:

Male Female

Address:

Primary Contact Number:

Employer:

Employer Address:

Employer Phone Number:

Insurance Company Name:

Type

PPO HMO Other

Policy / ID Number:

Co-Pay Amount:

Insurance Company Address:

Group Number:

SECONDARY SUBSCRIBER INFORMATION (IF APPLICABLE. DETERMINED BY ORDER OF BIRTH MONTH)

Secondary Subscriber’s Name (If different from above):

Birth Date:

Social Security Number:

Sex:

Male Female

Address (If different from above):

Primary Contact Number:

Employer:

Employer Address:

Employer Phone Number:

Insurance Company Name:

Type:

PPO HMO Other

Policy / ID Number:

Co-Pay Amount:

Insurance Company Address

Group Number:

The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Child and Adolescent Health Associates or insurance company to release any information required to process my claims.

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

Signature

Date

Your information will be encrypted.