LibertyMedhealthgroup.com - Patient Registration Form

PATIENT REGISTRATION FORM
PATIENT INFORMATION
Patient’s Name:

PrefixFirst NameMiddle NameLast Name
Marital Status:

SingleMarriedDivorcedSeparatedWidowed
Sex:

MaleFemale
Birth date:

MonthDayYear
Date
Age:
Social Security No.:
Home phone No.:
Please enter a valid phone number.
Cell phone No.:
Please enter a valid phone number.
Street address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation:
Employer:
Employer phone No.:
Please enter a valid phone number.
eMail:
example@example.com
If patient is a minor, please provide parent/guardian names and specify relation to the patient:
Referred to clinic by (please check one box):

Dr. Name:FamilyFriendWeb SearchIns. PlanHospitalOther:
IN CASE OF EMERGENCY
Name of local friend or relative (not living at same address):
Relationship:
Home phone No.:
Please enter a valid phone number.
Work phone No.:
Please enter a valid phone number.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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.
Person responsible for bill:
DOB:

MonthDayYear
Date
Address (if different):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home phone No.:
Please enter a valid phone number.
Occupation:
Employer:
Employer address:
Employer phone No.:
Please enter a valid phone number.
Work related?

YesNo
Auto Accident?

YesNo
If yes, on what date did the injury occur?

MonthDayYear
Date
Name of Primary Insurance:
Subscriber’s name:
Birth date:

MonthDayYear
Date
Group No.:
Policy No.:
Co-payment:
$
Patient’s relationship to the subscriber:

SelfSpouseChildOther
Name of Secondary Insurance :

(if applicable)
Subscriber’s name:
Birth date:

MonthDayYear
Date
Group No.:
Policy No.:
Co-payment:
$
Patient’s relationship to the subscriber:

SelfSpouseChildOther
PHARMACY
Pharmacy Name:
Pharmacy Address:
Phone Number:
Please enter a valid phone number.
Do you have an ADVANCE DIRECTIVE?

YesNo
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.
Patient/Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

PATIENT REGISTRATION FORM

PATIENT INFORMATION

IN CASE OF EMERGENCY

INSURANCE INFORMATION

Name of Primary Insurance:

Name of Secondary Insurance :

PHARMACY