PATIENT REGISTRATION FORM

PATIENT INFORMATION

First Name

Middle Initial

Last Name

Address (Street/Apt/Box):

(City, State, Zip)

Home Phone

Cell Phone

Work Phone

Birthday:

Gender

M F

Marital Status:

Social Security #

Employer:

INSURANCE INFORMATION

PRIMARY INSURANCE

Insured ID #:

Policy/Plan/Group #:

Copay:

Policyholder Name:

First, M.I., Last

Date of Birth:

Relationship:

Pre-Authorization required for visit?

Yes No

Authorization Number:

Number of Visits Authorized:

Dates Valid:

Primary Care Physician Name:

AUTHORIZATION OF BENEFITS:

I hereby authorize the practitioner whose name appears above to furnish my insurance company all information which the insurance company may request concerning my present illness or injury. I hereby assign to the practitioner whose name appears all money to which l am entitled for medical expenses relative to the service reported above but not to exceed my indebtedness to said practitioner, I understand that I am financially responsible to said practitioner for charges not covered by my insurance company.

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.

Patient Signature

Date:

Your information will be encrypted.