PRO SPINE & PAIN Patient Registration

PATIENT REGISTRATION FORM
PATIENT - THIS SECTION REFERS TO PATIENT ONLY
Please complete all information requested on this form
Name
Age
Date of Birth

MonthDayYear
Date
SS No.
Marital Status

SingleMarriedDivorcedWidowed
Sex:

MaleFemale
Maiden Name
Address
City
State
Zip Code
Home Phone
Cell Phone
Employer
Work Phone
RESPONSIBLE PARTY-THIS SECTION REFERS TO THE PERSON RESPONSIBLE FOR PAYMENT
Check which one applies

SelfPatient is a minor
See insurance information below.
PERSON TO CONTRACT IN CASE OF EMERGENCY
Name
Relationship
Phone
PRIMARY INSURANCE INFORMATION
Please check which one applies to you

InsuranceWorkmen's CompensationSelf Pay
Insurance Company's Name and Address
Phone Number
Insured's Name (who holds insurance)
Insured's Date of Birth

MonthDayYear
Date
Relationship to Patient
HIC/Policy Number or Social Security Number
Group Number
WORK COMP and MVA - REQUIRED INFORMATION
Case worker's name
Phone
Claim#
Date of Injury (REQUIRED)

MonthDayYear
Date
SECONDARY INSURANCE INFORMATION
Insurance Company's Name and Address
Phone Number
Insured's Name (who holds insurance)
Insured's Date of Birth

MonthDayYear
Date
Relationship to Patient
HIC/Policy Number or Social Security Number
Group Number
ASSIGNMENT OF BENEFITS
I hereby assign to Pain Physicians of Wisconsin any insurance or third-party benefits available for healthcare services provided to me. I understand that Pain Physicians of Wisconsin has the right to refuse or accept assignment of such benefits. If these benefits are not assigned to Pain Physicians of Wisconsin, I agree to forward the practice all health insurance and other third-party payments I receive for services rendered to me immediately upon receipt.
Signature of Patient / Legal Guardian

Clear
DATE

MonthDayYear
Date
Should be Empty:

PATIENT REGISTRATION FORM

PATIENT - THIS SECTION REFERS TO PATIENT ONLY

RESPONSIBLE PARTY-THIS SECTION REFERS TO THE PERSON RESPONSIBLE FOR PAYMENT

PERSON TO CONTRACT IN CASE OF EMERGENCY

PRIMARY INSURANCE INFORMATION

SECONDARY INSURANCE INFORMATION

ASSIGNMENT OF BENEFITS