Patient Registration Form

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

MonthDayYear
Date
SEX*

MALEFEMALE
SS#*
MARITAL STATUS*

SingleMarriedWidowedDivorcedSeparatedLife Partner
RACE

WhiteAfrican AmericanAsianDeclined
ETHNICITY

Not Hispanic/LatinoHispanic/LatinoDeclined
LANGUAGE

EnglishHispanicOther
Language Interpreter Required

YesNo
Do you have any communication difficulties/ special needs?

Hearing LossReading DifficultyVisually ImpairedOther
Address*
Apt #
City*
State*
Zip*
Home*
Cell*
Work
E Mail*
example@example.com
Take Photo
Employment Status

Full-TimePart timeUnemployedRetiredStudentOther
Employer/School
Address of the employer/school
Guarantor/Financially responsible party*

selfspouseparentguardianOther
Guarantor First name, MI*
Guarantor Last name*
Guarantor DOB*

MonthDayYear
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 referralTrident WebsiteAnother Physician/ProviderHospital / EDNewspaper/MagazineFriend/Family MemberInsurance CompanySocial MediaOther
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*

MonthDayYear
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?*

YesNo
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?*

YesNo
If yes, please list your Medicaid ID#
Primary Insurance (Commercial)*
SUBSCRIBER ID*
GROUP NUMBER
policy holder SS#
Secondary Insurance

yesno
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: