PATIENT REGISTRATION

PATIENT INFORMATION:

LAST NAME:

FIRST NAME:

MIDDLE INITIAL:

DATE OF BIRTH

SOCIAL SECURITY #:

SEX:

M F

STREET ADDRESS:

CITY:

STATE:

ZIP CODE:

REFERRING PROVIDER:

HOME PHONE #

WORK PHONE #

CELL PHONE #

EMAIL:

PREFERRED METHOD OF CONTACT (EMAIL, PHONE, CELL):

EMPLOYER INFORMATION:

COMPANY NAME

ADDRESS:

CITY:

STATE:

ZIP:

GENERAL INFORMATION: (OPTIONAL)

RACE:

ETHNICITY:

MARITAL STATUS:

STUDENT:

YES NO

RESPONSIBLE PARTY AND BILLING ADDRESS IF DIFFERENT AND SEASONAL ALTERNATE ADDRESS:

NAME OF RESPONSIBLE PERSON: (if other than self)

ADDRESS:

CITY:

STATE:

ZIP:

RELATIONSHIP:

PHONE NUMBER:

ALTERNATE PHONE NUMBER:

ALTERNATE ADDRESS:

CITY:

STATE:

ZIP:

EMERGENCY CONTACT INFORMATION:

NAME:

PHONE:

RELATIONSHIP:

INSURANCE INFORMATION: PLEASE GIVE ALL INSURANCE CARDS TO THE RECEPTIONIST TO COPY

IS CONDITION RELATED TO EMPLOYMENT?

YES NO

WORKERS COMPENSATION?

YES NO

1st INSURANCE NAME:

SUBSCRIBER NAME:

CO-PAY AMOUNT:

PATIENTS RELATIONSHIP TO SUBSCRIBER:

SELF SPOUSE CHILD OTHER

IF OTHER, SPECIFY:

POLICY HOLDER’S DATE OF BIRTH:

(if other than self)

2nd INSURANCE NAME

SUBSCRIBER NAME:

CO-PAY AMOUNT:

PATIENTS RELATIONSHIP TO SUBSCRIBER:

SELF SPOUSE CHILD OTHER

IF OTHER, SPECIFY:

POLICY HOLDER’S DATE OF BIRTH:

(if other than self)

3rd INSURANCE NAME:

SUBSCRIBER NAME:

CO-PAY AMOUNT:

PATIENTS RELATIONSHIP TO SUBSCRIBER:

SELF SPOUSE CHILD OTHER

IF OTHER, SPECIFY:

POLICY HOLDER’S DATE OF BIRTH:

(if other than self)

ONE TIME AUTHORIZATION FOR MEDICARE AND THIRD PARTY INSURANCE CARRIERS

I authorize the release of any medical information necessary to determine my benefits and to process any claim for services provided.

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

I authorize CMS or my insurance carrier to forward payment for medical benefits for all services provided to my physician or medical group.

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

Your information will be encrypted.