Western Wayne Medical New Patient Registration Form printable pdf download

WESTERN WAYNE MEDICAL

NEW PATIENT REGISTRATION FORM

(Please Print)

Please Note: We do NOT prescribe narcotic and addictive medicines.

Today’s date:

PATIENT INFORMATION

Patient’s last name:

First:

Middle:

Marital status (circle one)

 Mr.

 Miss

 Mrs.

 Ms.

Single / Mar / Div / Sep / Wid

Preferred Name:

Social Security #

Email address:

Birth date:

Age:

Sex:

 M

 F

Street address:

Cell Phone #:

Home phone #.:

(

)

(

)

Driver’s License State and #:

City:

State:

Zip Code:

Occupation:

Employer:

Employer phone #.:

(

)

 Dr.

 Insurance Plan

 Hospital

Chose clinic because/Referred to clinic by (please check one box):

 Family

 Friend

 Close to home/work

 Advertisement

 Internet

 Other

Race: African American

 Asian

 Caucasian (white)

 Other

Ethnicity:  American

 Hispanic or Latino

 Other

GUARANTOR INFORMATION (ONLY FOR PATIENT UNDER 18 YEAR-PERSON RESPOSIBLE FOR BILL)

Person responsible for bill:

Address (if different):

Home phone no.:

(

)

 Self  Spouse

Relationship:

Birth Date:

 Parent

 Other

Employer:

Employer address:

Employer phone no.:

(

)

 Active Duty

 Retired

 Deceased  Prime

 Standard

Is this patient covered by

If Tricare:

 Yes

 No

 Tri-care for Life

insurance?

Primary insurance

Policy Id#

Group #:

Effective Date:

 Co-pay $_______________

 Coinsurance: __________%

 Deductible per year $____________

Patient Responsibility:

Subscriber’s name:

Subscriber’s S.S. no.:

Birth date:

Group no.:

Policy no.:

Co-payment:

Patient’s relationship to subscriber:

 Self

 Spouse

 Child

 Other

Subscriber’s name:

Name of secondary insurance (if applicable):

Group no.:

Policy no.:

Patient’s relationship to subscriber:

 Self

 Spouse

 Child

 Other

Employer’s Phone #

Subscriber Employer Name

Employer Address

PHARMACY YOU PREFER TO USE

NAME:

ADDRESS:

PHONE:

IN CASE OF EMERGENCY

Name of local friend or relative:

Relationship to patient:

Home phone no.:

Cell phone no.:

(

)

(

)

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 Western Wayne Medical or insurance company to release any information

required to process my claims.

Signature of Patient or Parent of minor or Legal Guardian:

Name

Date

Western Wayne Medical New Patient Registration Form

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