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New Patient Registration Form
Get new patient records with this new patient registration form online. Fast registrations will make your life easier.
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Encrypted
Secure Form
Language
English (US)
Español
1
Name
First Name
Last Name
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2
Date of Birth
*
This field is required.
/
Date
Month
Day
Year
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3
Phone Number:
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4
E-mail
example@example.com
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5
Contact Number
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6
Do you consent to Text Messaging and/or Emails from Patient Bill Defender?
Please Select
Yes
No
Only Text
Only Emails
Please Select
Please Select
Yes
No
Only Text
Only Emails
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7
Date of service (If multiple, pick oldest ) If Hospital Stay, pick the discharge date.
-
Date
Month
Day
Year
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8
How many decisions need to be reviewed?
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9
Are any resulting bills in collections?
Please Select
Yes
No
Please Select
Please Select
Yes
No
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10
Date of the Denial Notice
-
Date
Month
Day
Year
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11
Type of Insurance?
Medicare Original
Medicare Advantage
Medicaid (Title XIX) (Welfare)
ACA Exchange Plan
Commercial Group Insurance (Through an Employer)
Self Insured
VA Benefits (Tricare, Champva, Champus)
Workers Compensation
Other
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12
Who is your insurance carrier?
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13
Is the insurance paid for even in part by a religious or government organization? (This tells me whether you have certain rights.)
Yes
No
Not Sure
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14
What is the Place of Service
Ambulatory Surgical Center (Not at a hospital)
Hospital ER or Overnight Stay
Hospital Outpatient Surgery
Infusion Center
Lab
Office Visit
Office Procedure
Urgent Care
Pharmacy
Other
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15
Why do you think the insurance is denying your claim?
*
This field is required.
Not Medically Necessary
Experimental/Investigational
Timely Filing
Out of Network
No Surprises Act
No Show Fee
Other Insurance (Coordination of Benefits)
Not insured on the date of service
Failed to get prior authorization
Overpayments
I think my insurance processed the claim incorrectly
Other
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16
Deadline to appeal (according to the paperwork) If its after the deadline, submit anyway as you may have protections.
-
Date
Month
Day
Year
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17
File Upload
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
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18
Feel free to type in any notes that you feel is important.
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