Adult Patient Registration - Galen Medical Group

Adult Patient Registration - Galen Medical Group

Primary Insurance Information
What primary health insurance are you covered by?
Insurance ID number
Relationship to subscriber?
Subscriber's name?
Insurance Subscriber's address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subscriber's Social Security Number?
Subscriber’s Date of Birth

MonthDayYear
Subscriber's Phone Number?
Adult Patient Registration - Galen Medical Group

Secondary Insurance Information
What secondary health insurance are you covered by?
Insurance ID number
Relationship to subscriber?
Subscriber's name?
Insurance Subscriber's address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subscriber's Social Security Number
Subscriber’s Date of Birth

MonthDayYear
Subscriber's Phone Number?
Adult Patient Registration - Galen Medical Group

Emergency Contact Information
Emergency Contact

First NameMiddle NameLast Name
Emergency Contact's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact's Relationship
Emergency Contact's Home Phone Number?
Emergency Contact's Work Phone Number?

Adult Patient Registration - Galen Medical Group

Dependent Service
If services are being provided to your dependent, please complete the following:
Mother/Guardian

First NameLast Name
Date of Birth

MonthDayYear
Social Security Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Father/Guardian

First NameLast Name
Date of Birth

MonthDayYear
Social Security Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
I herby authrorize Galen Medical Group, its physicians and staff to render medical care to my dependent listed under the patient information section on this form.
Signature*

Clear

Adult Patient Registration - Galen Medical Group

Consent for Release of Medical Information
Signature*

Clear
Authorized Person

First NameLast NameRelationship
Authorized Person's Phone Number

Area CodePhone Number
Authorized Person

First NameLast NameRelationship
Authorized Person's Phone Number

Area CodePhone Number
Authorized Person

First NameLast NameRelationship
Authorized Person's Phone Number

Area CodePhone Number
Adult Patient Registration - Galen Medical Group

Advanced Directives & Authorization
I AGREE TO NOTIFY GALEN MEDICAL GROUP, IN WRITING, IF THERE ARE ANY CHANGES IN THE PERSON(S) AUTHORIZED.
It is the right of every adult citizen in Tennessee and Georgia (18 years and over) to sign a Living Will, as well as a Durable Power of Attorney for Health Care that empowers an individual of your choosing to see that your wishes are carried out. It is important to decide whether or not you wish to sign a living will now when you are fully competent to make your own decisions. The choices you make in your living will will be binding on doctors, hospitals and other healthcare providers in the event you become incapable of telling them your wishes. If you have signed either document, please make sure your provider has a copy for your file.

I authorize Galen Medical Group, PC to release to my insurance company, managed care organization, state agency(ies), federal agency(ies), Health Care Financing Administration, Third Party Administrators, and/or Workers’ Compensation or its agents any information needed to process my claim and/or determine benefits payable for related services. I also authorize Galen Medical Group to utilize a fax machine to transmit any or all of the above medical records pertaining to my medical care or insurance reimbursement. I acknowledge that faxing my medical records may increase the risk of accidental disclosure of my medical records.

I grant permission to Galen Medical Group, PC to release all or part of my medical record to any consulting entity that may be involved in my medical care. This includes, but is not limited to, testing facilities, consulting physicians, and outpatient facilities.

I request that payment of Medicare, MediGap, Traveler’s Railroad Retirement, Managed Care Organization, Third Party Administrators, Commercial, Workers’ Compensation, Liability, and/or any other insurance benefits be made on my behalf to Galen Medical Group for services furnished to me or on my behalf by that provider.

I understand that I am financially responsible for deductible amounts, co-payments, co-insurance amounts, non-covered charges and any and all balances not covered under a contractual write-off agreement between Galen Medical Group, PC and my third party payer. My carrier’s failure to pay does not release me from this responsibility. I also agree that should this account be turned to collection, I will be responsible for all costs associated with debt collection, including attorney fees and court costs.

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