Login

Fillable Printable New Patient Registration Form

Fillable Printable New Patient Registration Form

New Patient Registration Form

New Patient Registration Form

Confidential Proprietary Information New Pt Reg Form Dec 2004
PATIENT REGISTRATION FORM
**Today’s Date: ________________________ Clinic Name: _______________________________________
PATIENT INFORMATION: (Please use full legal name, no nicknames)
*Last Name: _____________________________________ *First Name: ___________________________________ Middle Initial: ____________
*Address: _________________________________________________________________________________________________________________
City: ____________________________________________ State: ____________________________ Zip: ______________________
Home Phone #: (________) ________-_______________ *Social Security #: __________________________________________________
*Date of Birth: ____________________ Age: _________ *Sex: _______ Marital Status: ____________ Drivers Lic#: ______________
*Employer Name and Address: _______________________________________________________________________________________________
_______________________________________________________________________ Work Phone #: (________) ____________-_____________
E-mail Address: _________________________________________________________ Cell Phone #: (________) ____________-_____________
Emergency Contact Name: _______________________________________________ Emerg Phone #: (________) ___________-_____________
Please tell us how you heard about us: ________________________________Referred by___________________________________
GUARANTOR INFORMATION: (List person or insured name responsible for bill - use full legal name, no nicknames)
*Relationship of Guarantor to Patient: Self _____ Spouse _____ Parent ______ Other _____________________________
*Last Name: ___________________________________ *First Name: ___________________________________ Middle Initial: _____________
*Address: _________________________________________________________________________________________________________________
City: _____________________________________________ State: ____________________________ Zip: ______________________
Home Phone #: (__________) ______________-_____________________ *Social Security #: __________________________________________
*Date of Birth: _________________________ Age: ________________________ *Sex: Female _______ Male ________
*Employer Name and Address: _______________________________________________________________________________________________
__________________________________________________________________________ Work Phone #: (________)_________-__________
INSURANCE INFORMATION: (Please allow receptionist to photocopy your insurance ID cards)
IF SOMEONE OTHER THAN PATIENT IS THE INSURED PARTY, PLEASE INCLUDE DATE OF BIRTH FOR CLAIMS
PRIMARY INSURANCE:
Plan Name : __________________________________________ *Insured’s Name: ___________________________________
Insured’s Social Security #: _____________________________ *Insured’s Date of Birth: ____________________________
*Policy / ID #: _________________________________ *Group #: ________________________ Eff Date: ___________________
Claims Address & Phone: _______________________________________________________________________________________
SECONDARY INSURANCE:
Plan Name : __________________________________________ *Insured’s Name: ___________________________________
*Insured’s Social Security #: _____________________________ *Insured’s Date of Birth: ____________________________
*Policy / ID #: _________________________________ *Group #: ________________________ * Eff Date: ___________________
Claims Address & Phone: _______________________________________________________________________________________
*REQUIRED FIELDS-PLEASE COMPLETE FOR BILLING. *ATTACH COPY OF INSURANCE CARDS.
Please read and sign back of form.
Confidential Proprietary Information New Pt Reg Form Dec 2004
PATIENT REGISTRATION FORM
DISCLOSURES & CONSENTS
Patient Name: ________________________________________________________________ Date of Birth: _________________
First Name M.I. Last Name
ASSIGNMENT OF INSURANCE BENEFITS:
I hereby authorize direct payment of my insurance benefits to MedicalEdge Healthcare Group or the physician individually for services
rendered to my dependents or me by the physician or under his/her supervision. I understand that it is my responsibility to know my
insurance benefits and whether or not the services I am to receive are a covered benefit. I understand and agree that I will be responsible
for any co-pay or balance due that MedicalEdge is unable to collect from my insurance carrier for whatever reason.
MEDICARE/MEDICAID/CHAMPUS INSURANCE BENEFITS:
I certify that the information given by me in applying for payment under these programs is correct. I authorize the release of any of my or
my dependent’s records that these programs may request. I hereby direct that payment of my or my dependent’s authorized benefits be
made directly to MedicalEdge Healthcare Group or the physician on my behalf.
AUTHORIZATION TO RELEASE NON-PUBLIC PERSONAL INFORMATION:
I certify that I have received and read a copy of the MedicalEdge Healthcare Group Patient Information Privacy Policy. I hereby
authorize MedicalEdge Healthcare Group or the physician individually to release any of my or my dependent’s medical or incidental non-
public personal information that may be necessary for medical evaluation, treatment, consultation, or the processing of insurance benefits.
AUTHORIZATION TO MAIL, CALL OR E-MAIL:
I certify that I understand the privacy risks of the mail, phone calls, and e-mail. I hereby authorize a MedicalEdge Healthcare Group
representative or my physician to mail, call, or e-mail me with communications regarding my healthcare, including but not limited to such
things as appointment reminders, referral arrangements, and laboratory results. I understand that I have the right to rescind this
authorization at any time by notifying MedicalEdge Healthcare Group to that effect in writing.
LAB/X-RAY/DIAGNOSTIC SERVICES:
I understand that I may receive a separate bill if my medical care includes lab, x-ray, or other diagnostic services. I further understand
that I am financially responsible for any co-pay or balance due for these services if they are not reimbursed by my insurance for whatever
reason.
CONSENT TO TREATMENT:
I hereby consent to evaluation, testing, and treatment as directed by my MedicalEdge physician or his or her designee.
PATIENT SIGNATURE: _________________________________________________ DATE: ______________________
GUARANTOR SIGNATURE: _____________________________________________ DATE: ______________________
(If different from patient)
GUARANTOR NAME (Please Print): ______________________________________________________________________
Login to HandyPDF
Tips: Editig or filling the file you need via PC is much more easier!
By logging in, you indicate that you have read and agree our Terms and Privacy Policy.