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  • New Patient Registration 

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  • Emergency Contact Information

  • Insurance Information

    Please have your insurance card available
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  • Please attach a picture of your insurance card below.

    Ensure the picture is clear & the entire card is captured. If you are unable to attach a picture please bring your card with you to your first appointment
  • Assignment and Release:

  • I understand that I am financially responsible for charges incurred for services rendered. Full payment is expected at the time services are rendered. As a courtesy to you, we will submit your medical claim to your insurance company. I hereby authorize, and assign direct payment of my medical insurance benefits to Midwest Regional Health Services, LLC. I also authorize my medical provider to release my information requested by my medical insurance company.

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  • Please review the following MRHS Financial Policy

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  • Please review the following MRHS HIPPA Policy

  • I authorize Midwest Regional Health Services to disclose personal health information to the following people:

    (If you do not want any authorized individuals you may leave the following fields black)
  • Consent to Leave Phone Messages

    Do you authorize Midwest Regional Health Services to leave detailed messages regarding your care or lab results on your preferred phone number?
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