Medical Administration Mod 3

[NAME OF PRACTICE] REGISTRATION FORM

(Please Print)

Today’s date: PCP:

PATIENT INFORMATION Patient’s last name: First: Middle:  Mr.

 Mrs.  Miss  Ms.

Marital status (circle one)

Single / Mar / Div / Sep / Wid

Is this your legal name? If not, what is your legal name? (Former name): Birth date: Age: Sex:

 Yes  No / /  M  F

Street address: Social Security no.: Home phone no.:

( )

P.O. box: City: State: ZIP Code:

Occupation: Employer: Employer phone no.:

( )

Chose clinic because/Referred to clinic by (please check one box):  Dr.  Insurance Plan  Hospital

 Family  Friend  Close to home/work  Yellow Pages  Other

Other family members seen here:

INSURANCE INFORMATION (Please give your insurance card to the receptionist.)

Person responsible for bill: Birth date: Address (if different): Home phone no.:

/ / ( )

Is this person a patient here?  Yes  No

Occupation: Employer: Employer address: Employer phone no.:

( )

Is this patient covered by insurance?  Yes  No

Please indicate primary insurance  [Insurance]  [Insurance]  [Insurance]  [Insurance]  [Insurance]

 [Insurance]  [Insurance]  [Insurance]  Welfare (Please provide coupon)  Other

Subscriber’s name: Subscriber’s S.S. no.: Birth date: Group no.: Policy no.: Co-payment:

/ / $

Patient’s relationship to subscriber:  Self  Spouse  Child  Other

Name of secondary insurance (if applicable): Subscriber’s name: Group no.: Policy no.:

Patient’s relationship to subscriber:  Self  Spouse  Child  Other

IN CASE OF EMERGENCY Name of local friend or relative (not living at same address): Relationship to patient: Home phone no.: Work phone no.:

( ) ( )

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize [Name of Practice] or insurance company to release any information required to process my claims.

Patient/Guardian signature Date

1. Todays date:
2. PCP:
3. Patients last name First Middle:
4. salutation:
5. salutation_2:
6. Yes:
7. No:
8. If not what is your legal name:
9. Former name:
10. Birth date:
11. Age:
12. Sex:
13. Street address:
14. Social Security no:
15. Home phone no:
16. PO box:
17. City:
18. State:
19. ZIP Code:
20. Occupation:
21. Employer:
22. Employer phone no:
23. Chose clinic becauseReferred to clinic by please check one box:
24. Family:
25. Friend:
26. Close to homework:
27. Other:
28. Yellow Pages:
29. Dr:
30. Insurance Plan:
31. Hospital:
32. Other family members seen here:
33. Person responsible for bill:
34. Birth date_2:
35. Address if different:
36. Home phone no_2:
37. Is this person a patient here Yes No:
38. undefined:
39. undefined_2:
40. Occupation_2:
41. Employer_2:
42. Employer address:
43. Employer phone no_2:
44. Is this patient covered by insurance Yes No:
45. undefined_3:
46. undefined_4:
47. Insurance:
48. Insurance_2:
49. Insurance_3:
50. Insurance_4:
51. Insurance_5:
52. Welfare Please provide:
53. Insurance_6:
54. Insurance_7:
55. Insurance_8:
56. Other_2:
57. Subscribers name:
58. Subscribers SS no:
59. Birth date_3:
60. Group no:
61. Policy no:
62. Patients relationship to subscriber Self Spouse Child Other:
63. undefined_5:
64. undefined_6:
65. undefined_7:
66. undefined_8:
67. Name of secondary insurance if applicable:
68. Subscribers name_2:
69. Group no_2:
70. Policy no_2:
71. Patients relationship to subscriber Self Spouse Child Other_2:
72. undefined_9:
73. undefined_10:
74. undefined_11:
75. undefined_12:
76. Name of local friend or relative not living at same address:
77. Relationship to patient:
78. Date: