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Registration Form: (Name of Practice)

This registration form collects a patient's personal and insurance information including the patient's name, address, date of birth, employer, primary care provider, and emergency contact. Insurance details such as the subscriber's name, policy and group numbers, and patient's relationship to the subscriber are also requested. The patient signs acknowledging the information is accurate and authorizes the practice to release any necessary information to process insurance claims.

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Kasnopich
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74 views1 page

Registration Form: (Name of Practice)

This registration form collects a patient's personal and insurance information including the patient's name, address, date of birth, employer, primary care provider, and emergency contact. Insurance details such as the subscriber's name, policy and group numbers, and patient's relationship to the subscriber are also requested. The patient signs acknowledging the information is accurate and authorizes the practice to release any necessary information to process insurance claims.

Uploaded by

Kasnopich
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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[Name of Practice]

REGISTRATION FORM
Todays Date: [Date]

PCP: [PCP]
PATIENT INFORMATION

Patients last name: [Last Name]


Is this your legal name?

First: [First Name]

Middle: [Initial]

[Choose an item]

Marital status: [Choose an item]

If not, what is your legal name?

Former name:

Birth date:

Age:

[Legal Name]

[Former Name]

[Birthday]

[Age]

Sex:

Address: [Address/ P.O Box, City, ST ZIP Code]


Social Security no.:

Home phone no.:

Cell phone no.:

[SS#]

[Phone]

[Phone]

Occupation:

Employer:

Employer phone no.:

[Occupation]

[Employer]

[Phone]
[Doctors name]

Chose clinic because/referred to clinic by (Please choose one option):

[Choose an item]
Other family members seen here: [Other patients]
INSURANCE INFORMATION
(Please give your insurance card to the receptionist.)
Person responsible for bill:

Birth date:

Address (if different):

Home phone no.:

[Responsible party]

[Birthday]

[Address]

[Phone]

Is this person a patient here?

Is this patient covered by insurance?

Occupation:

Employer:

Employer address:

Employer phone no.:

[Occupation]

[Employer]

[Address]

[Phone]

Please indicate primary insurance: [Choose an item] | Other: [Other insurance]


Subscribers name:

Subscribers S.S. no.:

Birth date:

Group no.:

Policy no.:

Co-payment:

[Name]

[SS#]

[Birthday]

[Group #]

[Policy #]

$[Co-pay]

Patients relationship to subscriber: [Choose an item] | Other: [Relationship to subscriber]


Name of secondary insurance (if applicable):

Subscribers name:

Group no.:

Policy no.:

[Secondary Insurance]

[Name]

[Group #]

[Policy #]

Patients relationship to subscriber: [Choose an item] | Other: [Relationship to subscriber]


IN CASE OF EMERGENCY
Name of local friend or relative (not living at same address):

Relationship to patient:

Home phone no.:

Work phone no.:

[Friend or relative name]

[Relationship]

[Phone]

[Phone]

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

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