PATIENT REGISTRATION INCIDENT REPORT by pte15377

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									                                                                               PATIENT REGISTRATION
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                                                                                   INCIDENT REPORT
1100 Pacific Ave, Ste #300, Everett, WA 98201                                                                                                   For questions call (425) 339-2433

Registration Information
Patient Name:                                                                                                                                                   Male           ( )
Home Address:
                      Street
                                                                                           Home Phone:                                                          Female         ( )
City                                                                State                                              Zip

Marital Status: Single (                   )      Married (           )      Separated (              )   Divorced (               )    Widow/er (          )   Dependant      (     )
Birth date:                                                                 Age:                                Social Security #:
Primary Care Physician:                                                                                   Referred by Attorney:
Referred by Dr./patient/friend:
Patient’s Employer/School:                                                                                                       Driver’s License #:
Employment/School:                                                                                                                       Phone:
                                Street                       City                         State                   Zip

Parent/Spouse Name:                                                  Employer:                                                           Phone:
List Any Allergies:
List Any Current Medications:
Billing Information
Name of person responsible for bill:
                                                          Relationship                                                                                SS#
Address (if not as above):
                                         Street                                          City                                          State         Zip
Home Phone:                                                                                       Employer:
Work Phone:                                                                                       Address:

IN ORDER TO BILL YOUR INSURANCE, WE MUST HAVE A COPY OF YOUR CARD
PRIMARY INSURANCE                                                                                 ANY OTHER INSURANCE
Ins. Co. Name:                                                                                    Ins. Co. Name:
Subscriber Name:                                                                                  Subscriber Name:
Group #:                                          ID #:                                           Group #:                                         ID #:
Subscriber’s Employer:
Does your insurance carrier require a referral?
                                                                                                                       BRING YOUR INSURANCE CARD
                                                                                                                        BE PREPARED TO PAY, CO-PAY
Injury Information
Part of the body injured:                                                                  L      (       )   R    (         )      Date of injury:
How did the injury happen:                                                                  Employer at time of accident:
Where? Home (                  ) Auto (           ) Work (            )     Sports   (    )     School        (        )   Other   (    )      Claim Number:

Name of local person not living with you:                                                                                          Relationship:
Address:                                                                                                                         Phone #:
I request that payment of authorized Medicare of insurnce benefits be make to my physician on my behalp for any services furnished me
by any of the physicians of EB&J. I authorize any holder of medical information about me to release to HCFA and its agents or to my
other insurance any information needed to determine these benefits. I authorize treatment of the person named above and agree to pay
all fees and charges for such treatment, and I accept financial responsibility for non-covered services. In the event I default on this agree-
ment I agree to pay attorney fees. I further understand that a $5.25 Monthly Service Fee will be added to any balance over 60 days.


Signature:                                                                                                         Date:
                                                                                                                                                                Last update: July 31, 2008

								
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