you get to make up all the information

PATIENT REGISTRATION FORM

PLEASE PRINT NEATLY

TODAY’S DATE

:_________________

LAST NAME:__________________________________FIRST NAME:______________________MIDDLE INITIAL:______

STREET ADDRESS:_______________________________________________________APT. #_________________________

CITY/STATE/ZIP________________________________________________________________________________________

HOME PHONE:__________________________ CELL:__________________________EMAIL:_________________________

SS#:______________________________________DATE OF BIRTH:____________________________AGE:_____________

SEX: ____________MARITAL STATUS: Married__________Single__________Widowed__________Divorced___________

OCCUPATION:______________________________________EMPLOYER:________________________________________

WORK PHONE:______________________________WORK ADDRESS:___________________________________________

CITY/STATE/ZIP:________________________________________________________________________________________

SPOUSE NAME:_____________________________________________DATE OF BIRTH:_____________________________

EMPLOYER:________________________________________________WORK PHONE:_______________________________

INSURANCE PLAN:__________________________________NAME OF POLICYHOLDER:___________________________

POLICYHOLDER BIRTHDATE:_________________________RELATIONSHIP TO POLICYHOLDER:_________________

POLICYHOLDER ADDRESS (if different from the above address):_________________________________________________

CITY/STATE/ZIP:_______________________________________________PHONE:__________________________________

POLICYHOLDER EMPLOYER:___________________________________ POLICYHOLER SS#_______________________

SECONDARY PLAN (If applicable)________________________________POLICYHOLDER:__________________________

EMERGENCY CONTACT:________________________________________RELATIONSHIP:__________________________

(someone not living at your home as we will contact your immediate family members first if possible)

HOME PHONE:______________________________________CELL PHONE:_______________________________________

Release of Records:

I hereby authorize _______________ to release any information necessary for the completion of insurance claims for

payment from third party payers, including but not limited to: insurance companies, health maintenance organizations

government agencies and their representatives. I permit release of information concerning dates of treatment,

condition, diagnosis, procedures or surgeries to my personal physician, referring physician, and/or the referring

facility or for follow-up care.

___________________________________________________________________________________

Date

Patient Name

Signature of Patient/Responsible Party

Assignments of Benefits:

I accept financial responsibility for all services rendered. I understand that the billing office will file my insurance

claim if my physician/provider is a participating provider with my insurance carrier and I assign direct payment to the

physician all payments made under the terms and provisions of my policy. I further understand I am responsible for

payment for denied services regardless of the outcome of any dispute between myself and my insurance carrier. I

understand that I am responsible for and will pay my portion of the unpaid balance due for services performed by the

facility and physician/provider.

___________________________________________________________________________________

Date

Patient Name

Signature of Patient/Responsible Party

Progress Notes

Date: Patient Name: