MRHS New Patient Paperwork

Insurance Information

Please have your insurance card available
Billing Address *

Check if address is same as patient. Check if address is different from the patient and enter the details below
Address

Address

Street Address Line 2

City, State, Zip
Primary Insurance Company *
Ex: BCBS, United Healthcare, Aetna, etc.
Policy Number *
Group Number
If applicable: insurances may not include a group number on your card
Policy Holder's name (if different than patient)
Hint: Who is the insurance through?
Date of Birth of Policy Holder (if different than patient)

Month Day Year
Date
Secondary Insurance Company (if applicable)
Ex: BCBC, United Healthcare, Aetna, etc.
Policy Number
Group Number
If applicable: insurances may not include a group number on your card
Policy Holder's name (if different than patient)
Hint: Who is the insurance through?
Date of Birth of Policy Holder (if different than patient)

Month Day Year
Date
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
Primary Insurance Front of Card
Primary Insurance Back of Card
Secondary Insurance Front of Card
Secondary Insurance Back of Card

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.
Signature of Patient or Legal Guardian *

Clear
Name *
Relationship to Patient *
Hint: Self, Parent, Spouse, Daughter/Son, etc

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)
Name
Relationship to Patient
Hint: Self, Parent, Spouse, Daughter/Son, etc
Name
Relationship to Patient
Hint: Self, Parent, Spouse, Daughter/Son, etc
I wish to have the following restrictions to the use or disclosure of my protected health information other than those listed in Midwest Regional Health Services Privacy Policy
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?
Please Initial here ONLY IF YOU CONSENT to receive voicemails
Signature of Patient or Legal Guardian *

Clear
Name of Signee *
Relationship to Patient *
Hint: Self, Parent, Spouse, Daughter/Son, etc
Date *

Month Day Year
Date
Hour Minutes AM/PM Option
Should be Empty:

Emergency Contact Information