PATIENT REGISTRATION

PATIENT REGISTRATION
PLEASE PRINT AND COMPLETE ALL ENTRIES
PATIENT NAME*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
HOME PHONE
CELL PHONE*
PATIENT DATE OF BIRTH*

MonthDayYear
Date
PATIENT SSN
Gender*

MaleFemale
Marital Status

SingleMarriedOther
PATIENT EMPLOYER NAME
PATIENT EMPLOYER ADDRESS STREET ADDRESS CITY STATE ZIP
EMPLOYER PHONE
INSURED/RESPONSIBLE PARTY INFORMATION
RELATION TO PATIENT:

SpouseParentGuardian
NAME OF SUBSCRIBER OF HEALTH INSURANCE

First NameLast Name
ADDRESS if different from patient
HOME PHONE
WORK PHONE
SSN
BIRTH DATE

MonthDayYear
Date
EMPLOYER
INSURANCE INFORMATION
PRIMARY INSURANCE NAME
ADDRESS
PHONE
GROUP NUMBER
ID NUMBER
EMPLOYER
EMPLOYER PHONE
SECONDARY INSURANCE NAME
ADDRESS STREET CITY STATE ZIP
PHONE
GROUP NUMBER
ID NUMBER
EMPLOYER
EMPLOYER PHONE
PRIMARY DOCTORFAMILY DOCTOR
REFFERING DOCTOR
IN CASE OF EMERGENCY CONTACT
RELATIONSHIP
PHONE NUMBER
ASSIGNMENT AND RELEASE : I hereby authorize my insurance benefits be paid directly to the physician and I am financially responsible for non-covered services. I also authorize the physician to release any information required in the processing of this claim and all future claims. If my account is sent to a collection agency, I agree to pay all collection and attorney fees.
SIGNATURE Patient or if minor Signature of parent or guardian*

Clear
DATE

MonthDayYear
Date
Authorization to release health information to:
Names
ADDRESS
CITY STATE
ZIP
HOME PHONE
DAYTIME PHONE
DATES OF SERVICE
FROM
TO
AUTHORIZATION EXPIRES (UNLESS OTHERWISE NOTED THIS AUTHORIZATION WILL REMAIN IN EFFECT ONE YEAR FROM THE DATE SIGNED)
Date of Expiration

NeverOther
Release the following information:

All RecordsChart NotesRadiology ReportsOperative ReportsHistory and Physicals
Once "this facility" discloses my health information by my request, it cannot guarantee that Recipient will not re-disclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state laws governing the use and disclosure of my health information. I may make a request in writing at any time to inspect and/or obtain a copy of my health information maintained at this facility as provided in the Federal Privacy Rule 45 CFR (164.524 My records are protected and cannot be disclosed without written permission This Authorization will remain in effect for one year or until I provide a written notice of revocation to the Medical Record Department.
SIGNATURE OF PATIENT OR LEGAL REPRESENTATIVE

Clear
DATE

MonthDayYear
Date
EMAIL
example@example.com
Patient Signature or Legal Representative

Clear
If signed by legal representative, what is relation to the patient?
Should be Empty:

PATIENT REGISTRATION

PLEASE PRINT AND COMPLETE ALL ENTRIES

INSURED/RESPONSIBLE PARTY INFORMATION

INSURANCE INFORMATION

Authorization to release health information to:

DATES OF SERVICE

AUTHORIZATION EXPIRES (UNLESS OTHERWISE NOTED THIS AUTHORIZATION WILL REMAIN IN EFFECT ONE YEAR FROM THE DATE SIGNED)