Patient Registration Form

Laura Norton Petrovich, MD PC

1224 10th Street, Suite 200 Coronado, CA 92118

Today's Date:

PCP:

Patient Information

Last Name:

First Name:

Middle Name:

Is this your legal name?

Yes No

If not, what is your legal name?

(Former name):

Birthdate:

Age:

What sex is listed on your original birth certificate?

What is your gender identity?

Street Address:

City:

State:

Zip:

Social Security No.:

Phone:

Email:

P.O. box:

Occupation:

Employer or School:

Employer Phone No.:

How did you hear about our office?

Doctor Insurance Plan Hospital Family Friend Close to Home/Work Yellow Pages Other:

If doctor, which doctor?

If other, please specify:

Other family members seen here:

Insurance Information

(Please give your insurance card to the receptionist.)

Person responsible for bill:

Birth date:

Home Phone No.:

Address (If different):

City:

State:

Zip:

Is this person a patient here?

Yes No

Is this patient covered by insurance?

Yes No

Occupation:

Employer:

Employer Phone No.:

Employer Address:

City:

State:

Zip:

Please Indicate Primary Insurance:

Other:

Subscriber's Name:

Subscriber's S.S. No.:

Birthdate:

Group No.:

Policy no.:

Co-payment:

Patient’s relationship to subscriber:

Self Spouse Child Other

If other, please specify:

Name of secondary insurance (if applicable):

Subscriber’s name:

Group No.:

Policy no.:

Patient’s relationship to subscriber:

Self Spouse Child Other

If other, please specify:

In Case of Emergency

Name of local friend or relative (not living at same address):

Relationship to patient:

Home Phone No.:

Work Phone No.:

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Laura Norton Petrovich, MD PC 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 that your electronic signature is the legal equivalent of your manual signature on this application.

Patient/Guardian Signature:

Date:

Dear Patient:

Our office knows that insurance plans can be complicated, and we make every effort to answer your questions. It is up to you to know the requirements of your health plan prior to your visit. Please let us know if your plan requires you to use a contracted lab, radiology group or a certain group of specialists, doctors or hospitals. In addition, if your health plan requires a referral to see someone other than your primary care physician, be sure that the referral is approved before seeking care. Again, it is your responsibility to know the procedures and protocols of your health plan.

If your insurance requires a co-pay, please be prepared to pay at the time of your visit. Please bring your HMO or PPO/POS card to each visit in case we need to verify any insurance matters. If there is no eligibility for the date of the visit, be prepared to pay for the services at the time of the visit. Please be aware that some health plans do not cover well visits and vaccines, and you will be responsible for the balance due if this is the case.

Please do not assume that we know the details of your health plan. We deal with over 100 different plans, and each plan has different requirements and benefits.

We ask that you read your health plan booklet carefully and understand your coverage.

Thank you,

Laura Norton Petrovich, MD, and Staff

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.

Signature of Patient/Parent/Guardian:

Date:

No Show Policy

If a patient does not show for a scheduled appointment and does not cancel within 24 hours of the scheduled time, a $50 “no-show” fee will be assessed to the responsible party.

We have decided to implement this policy as some patients have consistently not shown for their appointments and given no prior notification, leaving us with fewer time slots for same-day appointments for other patients. We will fulfill our part by giving you a call the day before your appointment (on Friday if you have a Monday appointment scheduled.)

Our goal is not to penalize those who do not show for a scheduled appointment, but instead to free up the time to see those patients that need to be seen on a same-day basis. We really just want a courtesy call.

Thank you for making our office more easily accessible to our patients.

I acknowledge receipt of the no-show policy by signing below.

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.

Signature:

To help serve you better, please answer the following questions. The information you provide is voluntary and is meant to help us get a better understanding of the diversity of our population to improve the delivery of health care.

If other, please specify:

2. Which of the following ethnic groups do you consider yourself to be

Hispanic or Latino Non-Hispanic or Latino Decline to answer Unknown

3. With which of the following races do you identify?

Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Black or African American White Decline to answer Unknown

Your information will be encrypted.