Patient Registration Information

Y & D Clinic

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Please COMPLETE ALL sections below!

PATIENT'S PERSONAL INFORMATION

PATIENT'S / RESPONSIBLE PARTY INFORMATION

PATIENT'S INSURANCE INFORMATION

Please present insurance cards to receptionist.

PHARMACY INFORMATION

EMERGENCY CONTACT

Assignment of Benefits • Financial Agreement

I hereby give lifetime authorization for payment of insurance benefits to be made directly to Youens & Duchicela Clinic, and any assisting physicians for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by insurance. In the event of default I agree to pay all costs of collections, and reasonable attorney's fees. I hereby authorize this healthcare provider to release all information necessary to secure the payment of benefits. I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. I further agree that a photocopy of this agreement shall be as valid as the original.

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

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