New Patient Registration & Insurance Verification

New Patient Registration & Insurance Verification

Welcome to Jireh Medical Center. Please complete this secure form so our office can begin your registration and insurance verification process. Submission of this form does not guarantee coverage or confirm an appointment. A member of our team will contact you to confirm details.
Patient Information
Full Legal Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred Language
Best Time to Contact

Hour Minutes

AM/PM Option
Preferred Contact Method
Appointment Request
Reason for Visit
New Patient?
Preferred Appointment Date

MonthDayYear
Date
Preferred Appointment Time

Hour Minutes

AM/PM Option
Is This Urgent?
Seen at Jireh Medical Center Before?
Insurance Information
Insurance coverage, eligibility, copays, deductibles, and benefits must be confirmed by the insurance provider. Submission of this form does not guarantee coverage.
Insurance Provider Name
Member ID
Group Number
Policy Holder Name

First NameMiddle NameLast Name
Policy Holder Date of Birth

MonthDayYear
Date
Relationship to Patient
Front of Insurance Card

Cancelof
Back of Insurance Card

Cancelof
Photo ID

Cancelof
Medical Information
Primary reason for visit
Current medications
Allergies
Existing medical conditions
Preferred pharmacy name
Preferred pharmacy phone number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred pharmacy address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Consent and Acknowledgment
Acknowledgments
Emergency Notice
Patient Signature
Date

MonthDayYear
Date
Should be Empty:

New Patient Registration & Insurance Verification

Patient Information

Appointment Request

Insurance Information

Medical Information

Consent and Acknowledgment