PATIENT REGISTRATION FORM

PATIENT REGISTRATION FORM

This form can be used for all children UNDER AGE of 18
Patient Information
Name*

First NameLast Name
Primary Care Provider:
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Phone NumberPhone Number
Referring Provider:
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Phone NumberPhone Number
Patient's Reminders/Communication

This section is related to communication and Patient Portal access (See ‘Patient Portal FAQs’)

Please provide the contact information for the person who is to receive the reminders/communication for this patient.
Patient E-Mail
Mobile Phone

Phone NumberPhone Number
AppointmentsLab resultsHealth MaintenanceRx ConfirmationGeneralALLNone
Guardian Information:

(Please provide information other than parents)
Name

First NameLast Name
Phone Number

Phone NumberPhone Number
Relationship to Patient
Preferred Pharmacy Information:
Primary Pharmacy Name
Address
Phone Number

Phone NumberPhone Number
Insurance Information:

(Please provide a copy of ALL Insurance cards)
Worker's Comp IssueMVALegal CaseSchool InsuranceSelf-PayMedicaidMedicare
Primary Insurance Name:
Benefit Plan Name
Member ID: Group#: Effective Date:
Subscriber's Name:
Subscriber's DOB:
Take Photo of Your Primary Insurance Card (Front)
Take Photo of Your Primary Insurance Card (Back)
PCP listed on the card:
Secodary Insurance Name:
Benefit Plan Name
Member ID: Group#: Effective Date:
Subscriber's Name:
Subscriber's DOB:
PCP listed on the card:
Guarantor must initial to acknowledge that you are aware that you will receive the bill and be financially responsible for this patient.
Guarantor Initial:
Relationship: Self Spouse Other(specify):

Last Name: First Name:
Date of Birth:
By my signature, I acknowledge that I have read and understand the policies and procedures of Intensivist MD Support, LLC DBA: teleLung Specialists as defined in this packet that I received.
Address:
City, State, Zip:
Home Phone : Cell Phone:
Email:
Guarantor's Employer:
Work Phone:
Address:
City, State, Zip:
I, the undersigned, give my authorization to treat and assign directly to Intenvisit MD Support,LLC DBA:teleLung Specialists , all medical benefits if any, otherwise payable to me for services rendered. I understand that I am ultimately financially responsible for all approved and covered charges whether or not be paid by insurance. I authorize the doctor to release all information necessary to secure that payment benefits. I authorize that use of this signature on all my insurance submissions. I understand that payment is expected at the time of service. I also understand that there are administrative fees that I might incur related to non-direct medical care such as school forms, copy of charts, missed appointments, etc. I will be responsible for any bills that incur if insurance is terminated, rebilling fees related to this or any bill, as well as any collection, court costs and improper
scheduling of check-ups.

I AUTHORIZE THE PRACTICE TO USE AND DISCLOSE MY HEALTH INFORMATION FOR PURPOSES OF TREATING PATIENT, OBTAINING PAYMENT FOR SERVICES RENDERED TO ME AND CONDUCTING HEATHCARE OPERATIONS. I ACKNOWLEDGE THAT THERE IS A COPY OF THE HIPPA PRIVACY PRACTICES NOTICE POSTED IN THE OFFICE.
Patient Signature*

Clear
Date*

MonthDayYear
Date
Patient Name
Date*

MonthDayYear
Date
Patient/surrogate Signature*

Clear
Should be Empty: