Registration Form

Registration Form
Full Legal Name*
Preferred Name
Date of Birth*

MonthDayYear
Gender
Pronouns
Mailing Address*
City*
State*
Zip Code*
Email*
SSN*
Marital Status*
Cell Phone
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
CellHomeWork
Initial to consent to leave a detailed message*
Primary Insurance Information
Insurance Name
Insurance Phone
Format: (000) 000-0000.
Identification Number
Group Number
Name of Insured Party
Insured Party Date of Birth

MonthDayYear
Insured Party Employer
Insurance Effective Date

MonthDayYear
Relationship to Patient
MaleFemale
Secondary Insurance Information
Insurance Name
Insurance Phone
Format: (000) 000-0000.
Identification Number
Group Number
Name of Insured Party
Insured Party Date of Birth

MonthDayYear
Insured Party Employer
Insurance Effective Date

MonthDayYear
Relationship to Patient
MaleFemale
Guarantor
PatientOther
Guarantor Name
Date of Birth

MonthDayYear
Mailing Address
City
State
Zip Code
Emergency Contact
Name*
Relationship*
Phone Number*
Format: (000) 000-0000.
Initial to consent to release medical information to emergency contact*
Authorization
I authorize Journey Family Medicine Associates to bill the above insurance on my behalf, and assign any insurance benefits payable directly to Journey Family Medicine Associates. I understand that I am financially responsible for all non-covered services.
Signature*
Today's Date*

MonthDayYear
Should be Empty: