REGISTRATION FORM

REGISTRATION FORM
Today’s Date

MonthDayYear
Date
Primary Care Provider
PATIENT INFORMATION
Patient’s last name
First
Middle
Prefix

Mr.Mrs.MissMs.
Marital status

SingleMarriedDivorcedSeparatedWidowed
Is this your legal name:

YesNo
If not, what is your legal name?
(Former name)
Birth date

MonthDayYear
Date
Age:
Age:

MF
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security no.:
Home phone no.:
Please enter a valid phone number.Format: (000) 000-0000.
Occupation
Employer
Employer phone no.:
Please enter a valid phone number.Format: (000) 000-0000.
Chose clinic because/referred to clinic by (Please check one box)

Dr.Insurance planHospitalFamilyFriendClose to home/workYellow PagesOther
Who was the doctor that referred you?
Other family members seen here
INSURANCE INFORMATION

(Please give your insurance card to the receptionist
Person responsible for bill
Birth date

MonthDayYear
Date
Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home phone no.:
Please enter a valid phone number.Format: (000) 000-0000.
Is this person a patient here?

YesNo
Occupation
Employer
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer phone no.:
Please enter a valid phone number.Format: (000) 000-0000.
Is this person covered by insurance?

YesNo
Please indicate primary insurance
Subscriber’s name
Subscriber’s S.S. no.
Birth date

MonthDayYear
Date
Group no.
Policy no.
Co-payment
Patient’s relationship to subscriber:

SelfSpouseChildOther
Name of secondary insurance (if applicable):
Subscriber’s name:
Birth date

MonthDayYear
Date
Group no.
Policy no.
Patient’s relationship to subscriber:

SelfSpouseChildOther
IN CASE OF EMERGENCY
Name of local friend or relative (not living at same address):
Relationship to patient:
Home phone no.:
Please enter a valid phone number.Format: (000) 000-0000.
Work phone no.:
Please enter a valid phone number.Format: (000) 000-0000.
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Radiology Associates or insurance company to release any information required to process my claims.
Patient/Guardian signature
Date

MonthDayYear
Date
Should be Empty:

REGISTRATION FORM

PATIENT INFORMATION

INSURANCE INFORMATION

IN CASE OF EMERGENCY