Immanuel Family Practice, P by Mg7kd8

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									  Emmanuel Family Clinic                                              Date_________________________
  Patient Registration
                                               Patient Information (Please Print)

  Last Name__________________________________First Name___________________________________

  Address________________________________________________________________________________

  City__________________________________________State____________________Zip_______________

  Date of birth_____________________________Social Security Number_____________________________

  Home Phone_____________________Work________________________Cell________________________

  Gender M F Marital Status S M W D Employer_______________________________________________

  Emergency
  contact:_________________________________Phone________________________Relationship________

                                    Insured Information (if other than patient)

  Name of insured__________________________________SSN_________________________Gender M F

  Relationship to patient___________________________Date of Birth________________________________

  Employer__________________________________________Work Phone___________________________

                                      Responsible Party (if other than patient)

  Name of person responsible for this account____________________________________________________

  Relationship to patient___________________________Date of Birth________________________________

  Employer__________________________________________Work Phone___________________________

  SSN_________________________________________Driver’s License Number______________________


Authorization to release information: I hereby authorize Immanuel Family Practice, P.A., to release all information
pertaining to patient’s treatment to his/her insurance company/companies and to any other physician or health care
provider to whom the patient may be referred.

Assignment of benefits: I hereby assign all medical and surgical benefits, to include major medical benefits to which I
am entitled, including Medicare, Medicaid, private insurance, and any other health plan to Immanuel Family Practice, P.A.

Financial Policy: We will file your insurance if you provide us the accurate information. Please remember that your
insurance policy is a contact between you and your insurance company, not our practice. It is your responsibility to be sure
your bill is paid in full.

____________________________________________________                                      _______________________
SIGNATURE OF PATIENT/RESPONSIBLE PARTY                                                                 Date

								
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