Patient Registration Form

FIRST NAME, MIDDLE INITIAL (AS LISTED IN INSURANCE) *
LAST NAME (AS LISTED IN INSURANCE) *
DOB *

Month Day Year
Date
SEX *

MALE FEMALE
SS# *
MARITAL STATUS *

Single Married Widowed Divorced Separated Life Partner
RACE

White African American Asian Declined
ETHNICITY

Not Hispanic/Latino Hispanic/Latino Declined
LANGUAGE

English Hispanic Other
Language Interpreter Required

Yes No
Do you have any communication difficulties/ special needs?

Hearing Loss Reading Difficulty Visually Impaired Other
Address *
Apt #
City *
State *
Zip *
Home *
Cell *
Work
E Mail *
example@example.com
Take Photo
Employment Status

Full-Time Part time Unemployed Retired Student Other
Employer/School
Address of the employer/school
Guarantor/Financially responsible party *

self spouse parent guardian Other
Guarantor First name, MI *
Guarantor Last name *
Guarantor DOB *

Month Day Year
Guarantor SSN *
example@example.com
Guarantor Address *
Apt #
City *
State *
Zip *
Home *
Cell *
EMERGENCY CONTACT *
Relationship to Patient *
Home *
Cell
How did you hear about us ?

PCP referral Trident Website Another Physician/Provider Hospital / ED Newspaper/Magazine Friend/Family Member Insurance Company Social Media Other
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

I authorize Trident Heart and Vascular and its representatives to use the additional contact/guarantor information listed above to discuss or disclose information regarding any matters relating to my appointments, billing information and/or medical care. This authorization will remain in effect until I provide written notification to Trident Heart and Vascular of changes or update.
Signature *

Clear
Date *

Month Day Year
If you wish to receive your health information by email, please continue to read. Sending health information by unencrypted email may pose some risk that the health information in the unencrypted email could be read by a third party over the Internet.
Signature *

Clear
By signing below, I declare that the insurance and ID proof provided at each visit is current and valid
Signature *

Clear
INSURANCE INFORMATION
Do you have Medicare? *

Yes No
If you answered NO, skip to medicaid section/primary insurance
If Yes, Please list Medicare ID#
Medicare Supplement
name of the supplement plan
Medicare Supplement ID#
Medicare Advantage Plan
Medicare Advantage Plan ID#
Are you a Medicaid Beneficiary? *

Yes No
If yes, please list your Medicaid ID#
Primary Insurance (Commercial) *
SUBSCRIBER ID *
GROUP NUMBER
policy holder SS#
Secondary Insurance

yes no
If yes to secondary insurance, please enter insurance information
Secondary insurance
Secondary insurance subscriber ID
Other insurance plans
Take Photo of your insurance (front)
Take Photo of your insurance (back)
MEDICATION REFILL
Please contact your pharmacy for medication refills. Your Pharmacy will fax us a medication refill request which the physician will review. Refill authorizations may require 48-72 hours. Please allow sufficient time for us to process your refill request.
Pharmacy Name
Pharmacy address
Phone
Should be Empty:

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