PATIENT REGISTRATION

GUARANTOR INFORMATION

LAST NAME

FIRST NAME

INITIAL

Home Phone

Work Phone

Cell Phone

ADDRESS

CITY

STATE

ZIP CODE

EMERGENCY PHONE & CONTACT PERSON

OUT OF TOWN PHONE

OUT OF TOWN ADDRESS

CITY

STATE

ZIP CODE

SOCIAL SECURITY NO.

DRIVER'S LICENSE NO.

E-MAIL

EMPLOYER

ADDRESS

CITY

STATE

ZIP CODE

PATIENT INFORMATION

PATIENT NAME

BIRTH DATE

ADDRESS IF DIFFERENT FROM ABOVE

REFERRING PHYSICIAN OR OTHER SOURCE OF REFERRAL

FAMILY PHYSICIAN

INSURANCE INFORMATION

PRIMARY INSURANCE CARRIER & ADDRESS

GROUP NO.

CONTRACT NO.

SECONDARY INSURANCE CARRIER & ADDRESS

GROUP NO.

CONTRACT NO.

NAME OF INSURED

BIRTH DATE

RELATIONSHIP TO PATIENT

FEES & BILLING INFORMATION

Our billing procedures are clear. Please take a few moments and acquaint yourself with our credit policy:

Payment is expected at the time of service by cash, check or credit card (Visa/Master Card).
You will receive an itemized statement for all services rendered to you on the same day of service.
All accounts past due over 60 days are to be paid by the patient prior to the next visit.
A rebilling charge of 1 ½% per month will be added to any unpaid balance over 60 days from the day of service.
All accounts 90 days or older are handled exclusively by a collection agency and a collection fee will be added to the balance.

AUTHORIZATION (PLEASE READ CAREFULLY BEFORE SIGNING)

I consent to and authorize this medical facility, its doctors and staff to diagnose and treat my condition.
No promise for cure has been given to me.
My signature below can act as a signature on file for filing insurance claims on my behalf.
I authorize the release of medical information needed to establish my claim.
I understand this office cannot accept the responsibility for collecting my insurance claims.
I understand this office cannot accept the responsibility of negotiating a settlement of my claim.
I acknowledge the initial visit charges have been explained to me at the time I made the appointment.
I understand the billing, fees and credit policies of this facility as outlined above.
I understand the provider’s charge may exceed the insurance payment and if greater than such payment, I am responsible for the amount.
I acknowledge that I have access to the notice of Privacy Practices (HIPPA) located in a three ring binder at your business office desk and that I will read it, if I so choose.

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

SIGNATURE

DATE

WITNESS

BELOW FOR OFFICE USE ONLY… INSURANCE COVERAGE %

OFFICE VISITS

LAB TESTS

ALLERGY TESTING

ALLERGY INJECTION

ALLERGY EXTRACTS

VERIFICATION NO.

EFFECTIVE DATE

DEDUCTABLE:

MET:

NOT MET:

COPAY

verified by

DATE

Your information will be encrypted.