Patient Registration - PATIENT INFORMATION RECORD by wuyunyi

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									                                                                                                             Initial Appt Date:
     ______
                                                                        Time: _______________

                                                        Patient Registration
Patient’s Name: ________________________________________________                                    Date: _____________________

Home Address: _______________________________________ City: ________________ State: ______ Zip: _______
Daytime # : (     )                   Evening# : (      )                 Cell# : (    )
Date of Birth: __________ Social Security# ________________ Age:_____ Sex:____ Ht: _____ Wt: _____
Martial Status: __Single __Married __Divorced __ Separated __ Widowed
Race: __White __African American __American Indian __Alaska Native __ Pacific Islander __ Wish not to answer
Email Address: ____________________________________________________________________________________
Employment Status:   __Full time __ Part time __ Self Employed __ Homemaker __ Student __ Retired
                     __ Disabled __ Unemployed __ Wish not to answer
Occupation: __________________________Employer:_____________________ Employer Phone # : ( )___________

Employer Address: ____________________________________ City: ________________ State: ______ Zip: _______
Emergency Contact: ____________________ Relationship: _________________ Phone # : (                           )_________________
Would it be best to contact you by __phone or __ email? If by phone when is the best time of day to reach you between 8
am and 5 pm? _____________ At what number? _______________ Any specific day of the week? _________________
                               How Did You Hear About Us? (Check all that apply)
□ TV ( channel?) ____________ _____ □ Radio (station?) ________ □ Newspaper (publication?) ________________
□ Internet (site?) _________________ □ Billboard                                 □ Doctor (name?) ________________________
□ Word of Mouth                              □ Friend                            □ Patient

                                            Primary Insurance Information
Do you plan on financing the surgery or paying out of pocket? ___ Yes ___ No If yes, skip this information

Insurance name: ___________________ Phone # _________________ Claims address: _________________________
Policy #: ______________________ Group#: ____________________________ ID# ___________________________
Subscriber’s relationship to Patient:     __________________________ (if Self, skip to the next section)
Subscriber’s Name: ________________________________________________________________________________
                   Last Name                             First Name
Subscriber’s Social Security # ______________________________Subscriber’s Date of Birth: _____________________


                                              Secondary Insurance (If Applicable)

Insurance name: ___________________ Phone # _________________ Claims address: _________________________
Policy #: ______________________ Group#: ____________________________ ID# ___________________________
Subscriber’s relationship to Patient:     __________________________ (if Self, skip to the next section)

Subscriber’s Name: ________________________________________________________________________________
                   Last Name                             First Name
Subscriber’s Social Security # ______________________________Subscriber’s Date of Birth: _____________________

I, the undersigned, certify that the above information given by me is correct. I request that payment of authorized benefits be made on
my behalf. I assign the benefits payable for physicians’ services to the physician or organization furnishing the services and authorize
such physician or organization to submit a claim to Medicare or other insurance carrier on my behalf.
Patient Signature: ______________________________________   Date: __________________________________________

								
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