Patient Registration Form Chart - Black Hills Ob-Gyn

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PATIENT REGISTRATION FORM
Chart # ___________________
Date _____________
Patients Name ____________________________________ Date of Birth ____________________ Age ______
Last
First
MI
Address ________________________________ City ________________________ State _______ Zip ______
Patients Social Security # _____________________ Marital Status S M W D
CONTACT INFORMATION
You have the right to request that our practice contact you about your health needs and related issues in a particular manner. Please be advised that
this includes lab and test results, diagnosis, appointment and follow up care plans. Please indicate the acceptable means of contacting you.
Home # ___________________
Can we leave an answer on your machine Y N
Cell # _____________________
Can we leave a message on your voicemail Y N
Work # ____________________
Can we leave a message on your voicemail Y N
By Mail _____________________________________________________________
Who should we contact in the event of an emergency? _________________________________ Phone # _______________________
What is their relationship to you? ________________________________________________________________________________
INSURANCE INFORMATION
Primary
Copy of Card Attached Initial __________
Primary Insurance Co _______________________ Policy # ________________ Group # ________________
Policy Holders Name _______________________ Date of Birth ____________ SS# ____________________
Policy Holders Employer ____________________ Employer Address ________________________________
Secondary
Copy of Card Attached Initial __________
Secondary Insurance Co _____________________ Policy # ________________ Group # ________________
Policy Holders Name _______________________ Date of Birth ____________ SS# ____________________
Policy Holders Employer ____________________ Employer Address ________________________________
If patient is a minor please indicate who is financially responsible ____________________________________
For marketing purposes how did you come to choose BlackHills Ob/Gyn ______________________________
(Please turn over and fill out the reverse side)

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