Patient Registration Form

SECTION II: PATIENT HOUSEHOLD INCOME INFORMATION

Please view the chart below and select your family size and annual household income range from the corresponding dropdown menu (first find family size then find income range in same row)
Please select your family size from the dropdown menu*
For a family size of 1, select your annual income range from the dropdown menu
For a family size of 2, select your annual income range from the dropdown menu
For a family size of 3, select your annual income range from the dropdown menu
For a family size of 4, select your annual income range from the dropdown menu
For a family size of 5, select your annual income range from the dropdown menu
For a family size of 6, select your annual income range from the dropdown menu
For a family size of 7, select your annual income range from the dropdown menu
For a family size of 8, select your annual income range from the dropdown menu
SECTION III: INSURANCE INFORMATION
Insurance Name:*
Type N/A if this does not apply
Policy Number/Enrollment ID*
Type N/A if this does not apply
Group ID*
Type N/A if this does not apply
Member ID*
Type N/A if this does not apply
SECTION IV: EMERGENCY CONTACT INFORMATION
Emergency Contact Name*
Relationship to Patient
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about Charles Drew Health Center, Inc.?

SECTION V: FINANCIAL RESPONSIBLE PARTY INFORMATION

Should match insurance card, if applicable. Only complete this section if the responsible party is different from patient.
Name

First NameLast NamePreferred NameMiddle Initial
Social Security Number (SSN)
Date of Birth (mm/dd/yyyy)

MonthDayYear
Address

Street Address

Street Address Line 2

CityState

Zip Code
Please fill out any/all contact methods.
Cell Phone*
Please enter a valid phone number.Format: (000) 000-0000.
May we leave a voicemail?

YesNoN/A
Alt. Phone
Please enter a valid phone number.Format: (000) 000-0000.
May we leave a voicemail?

YesNoN/A
Email Address
example@example.com
Preferred Language
Interpreter Needed?

YesNo
I authorize release of information regarding continuation of care and/or any payments for services. I authorize a copy of this document may be used as the original document. I certify all information provided is true and accurate to the best of my knowledge.
Patient Signature*
Date*

MonthDayYear
F1014 / APPROVED FOR USE / 4.1.25-4.1.26

Please note that for privacy reasons, we are unable to respond via email to questions regarding specific health concerns.
Please verify that you are human*
Should be Empty:

PATIENT REGISTRATION FORM