AULIKE HEALTH PARTNERS LLC PATIENT REGISTRATION FORM 18+

Please correct the errors described below.

Today’s Date

Patient’s Name (Last, First, Middle)

Nickname

Sex, Gender Identity, Preferred Pronoun(s)

Date of Birth

Preferred Email Address (for appointments and contacting)

Preferred Cell Phone Number (for appointments and contacting)

Billing Address (if different than above)

Attention to (name)

Relationship to patient (guardian, other)

Address

City

State

Zip

Emergency Contact Information

Name of local friend or relative

Relationship to patient

Phone Number

Insurance Information

Is this patient covered by insurance?

No, I will pay for visit Yes (please provide copy of insurance card)

1. Primary Insurance:

HMSA

QUEST-HMSA

Tricare

Other

If other, please specify.

Subscriber ID #

(social security # if Tricare)

Coverage Code

Group

Effective Date

Subscriber Name

Patient’s relationship to subscriber

Self Child

Sex

M F

Date of Birth

2. Secondary Insurance:

HMSA

QUEST-HMSA

Tricare

Other

If other, please specify.

Subscriber ID #

(social security # if Tricare)

Coverage Code

Group

Effective Date

Subscriber Name

Patient’s relationship to subscriber

Self Child

Sex

M F

Date of Birth

I certify that the above information is accurate and current to the best of my knowledge. By providing my cell phone number and/or email address, I consent to Aulike Health Partners LLC contacting me regarding my medical care via cell phone, text or email.

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.

Name

Signature

Date

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