Patient Registration

Name of Practice*

Select name of clinic/practice where you are being seen

Name of Practice (Text Field)

Enter name of clinic/practice where you are being seen

Patient's Full Name*

First NameLast Name

Date of Birth*

Gender

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Email Address*

example@example.com

Cell Phone Number*

Please enter a valid phone number.

May we leave a message on your cell phone?*

YesNo

Type of Service

MaternityWell WomanPregnancy ConfirmationOther

Have you had an unmedicated previous pregnancy?*

Select "No" if you are unsure

Primary Insurance Company*

Insurance ID *

Group Number*

Policy Holder Name*

First NameLast Name

Relationship to Policy Holder*

Example(s): Self, Parent, Partner

Policy Holder DOB*

Secondary Insurance Company (if applicable)

Secondary Insurance ID

Group Number - Secondary

Policy Holder Name - Secondary

First NameLast Name

Relationship to Policy Holder - Secondary

Example(s): Self, Parent, Partner

Policy Holder DOB - Secondary

Photo ID

Insurance Card

Consent for Release of Medical Information:

I hereby authorize TOTAL HEALTHCARE BILLING, LLC to use and disclose my protected health information for the purposes of treatment, payment, and healthcare operations. TOTAL HEALTHCARE BILLING, LLC is permitted to file claims with my insurance on my behalf. I authorize the release of any medical information or documentation about me to any insurance company or its agents to facilitate the determination of benefits, both now and in the future.

I will notify TOTAL HEALTHCARE BILLING, LLC of any changes to my insurance or contact information. This authorization will remain in effect from the date signed until revoked in writing.

Financial Responsibility Agreement

I acknowledge my financial responsibility for all medical charges and services provided to me, regardless of insurance coverage. I accept responsibility for any balance that remains unpaid by my insurance company within 90 days of claim submission. A fee of $30 will be applied to all returned checks. I agree to cover any costs associated with collections, including attorney fees, court costs, and legal interest that may arise from enforcing this obligation.

Notice: Since your completed verification of benefits and financial plan documents contain protected health information, they will be sent to you in an encrypted format. If you prefer to receive them unencrypted, please reply to the email you receive authorizing the unencrypted transmission of these documents.

Printed Name*

First NameLast Name

Signature

Date

Is your insurance through Medicaid or Tricare? *

Are you a self-pay client?*

Payment Information

Verification of Benefits FeeThe Verification of Benefits (VOB) Fee is a charge assessed for the process of confirming insurance coverage and benefits.

$25

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Patient Registration Form

Insurance Information

Attachments

Consent and Authorization