PATIENT REGISTRATION FORM

BLUE RIDGE BEHAVIORAL HEALTH SERVICES: Patient Registration

170 Thomas Johnson Drive, Suite 200, Frederick, MD 21702
Today's Date:

MonthDayYear
Home Phone:
Date of Birth:

MonthDayYear
Patient's Last Name:*
First Name:*
Middle:
Driver's License #:
Address (no PO Boxes please)
City
State
Zip Code
Sex

MFOther
Social Security
Marital Status

SingleMarriedDivorcedSeparatedWidowed
Patient's Employer
Employer Phone:
Business Address
Name of Person Responsible for Payment
Emergency Contact
Emergency Phone
IF PATIENT IS A MINOR, COMPLETE THE FOLLOWING
SECTION I
Mother/Guardian Name
Home Phone:
Address (no PO Boxes please)
City
State
Zip Code
Date of Birth:

MonthDayYear
Social Security
Mother/Guardian Employer
Occupation
Business Address
Business Phone
SECTION II
Father/Guardian Name
Home Phone:
Address (no PO Boxes please)
City
State
Zip Code
Date of Birth:

MonthDayYear
Social Security
Father/Guardian Employer
Occupation
Business Address
Business Phone
Insurance Information
Last Name of Insured
First Name of Insured
Middle of Insured
Insured's Date of Birth

MonthDayYear
Insured's Social Security Number
Insurance Policy Number
Group Number
Relationship to Patient

SelfSpouseParentGuardianOther
Insured's Address
Insured's Employer
Business Phone
Employer's Address
Name of Insurance Company
Address of Insurance Company
City
State
Zip
Insurance Company Phone Number
Effective Date of Coverage

MonthDayYear
Front of Insurance Card (Upload Photo)

Browse Files

Cancelof
Back of Insurance Card (Upload Photo)

Browse Files

Cancelof
Should be Empty:

IF PATIENT IS A MINOR, COMPLETE THE FOLLOWING