LibertyMedhealthgroup.com - Patient Registration Form

  • PATIENT REGISTRATION FORM

  • PATIENT INFORMATION

  • Marital Status:
  • Sex:
  • Birth date:
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Referred to clinic by (please check one box):

  • IN CASE OF EMERGENCY

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • INSURANCE INFORMATION

    (Please give your insurance card(s) to the receptionist)

  • If the patient is responsible for his/her bill, please skip the next section.

    The guarantor is the person responsible for the patient’s bill. If the patient is a minor (under the age of 18), the parent or guardian bringing the patient to the visit is usually the guarantor for the patient.

  • DOB:
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Work related?
  • Auto Accident?
  • If yes, on what date did the injury occur?
     - -

  • Name of Primary Insurance:

  • Birth date:
     - -
  • Patient’s relationship to the subscriber:

  • Name of Secondary Insurance :

    (if applicable)
  • Birth date:
     - -
  • Patient’s relationship to the subscriber:

  • PHARMACY

  • Format: (000) 000-0000.
  • Do you have an ADVANCE DIRECTIVE?

  • The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the physician. I understand that I amfinancially responsible for any balance. I also authorize LibertyMed Health or insurance company to release any information required to process my claims.

  • Date
     - -
  • Should be Empty: