Patient Registration

Patient Registration Form
Name of Practice*
Select name of clinic/practice where you are being seen
Have you previously had a birth at Atlanta Birth Center?
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*

MonthDayYear
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 a previous unmedicated pregnancy at a hospital or birth center?*
Select "No" if you are unsure
Insurance Information

Please provide the patient's insurance information.
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*

MonthDayYear
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

MonthDayYear
Attachments
Photo ID*

Cancelof
Insurance Card *

Cancelof
Consent and Authorization
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

Clear
Date

MonthDayYear
Is your insurance through Medicaid or Tricare?
Are you a self-pay client?
***Roots Community Birth Center Patients Only ***

This form is intended for insurance billing estimates only and should not be used for Medicaid or Self-Pay estimates
***Magnolia Patients Only ***

This form is intended for insurance billing estimates only and should not be used for Medicaid or Self-Pay estimates
Estimated Due Date?*

MonthDayYear
Date
Are you an existing patient?

My Products

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

$25.00

Total

$0.00

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

Should be Empty:

Patient Registration Form

Insurance Information

Attachments

Consent and Authorization

***Roots Community Birth Center Patients Only ***

***Magnolia Patients Only ***

Roots Community Birth Center Patients Only

Magnolia Patients Only