Registration Form - The Center For Integrative Healthcare

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THE CENTER FOR INTEGRATIVE HEALTHCARE
REGISTRATION FORM
(Please Print)
Today’s date:
PCP:
PATIENT INFORMATION
Patient’s last name:
First:
Middle:
Marital status (circle one)
 Mr.
 Miss
 Mrs.
 Ms.
Single / Mar / Div / Sep / Wid
Is this your legal name?
If not, what is your legal name?
(Former name):
Birth date:
Age:
Sex:
 Yes
 No
 M
 F
/
/
Street address:
Social Security no.:
Home phone no.:
(
)
P.O. box:
City:
State:
ZIP Code:
Occupation:
Employer:
Employer phone no.:
(
)
 Dr.
 Insurance Plan
 Hospital
Chose clinic because/Referred to clinic by (please check one box):
 Family
 Friend
 Close to home/work
 Yellow Pages
 Other
INSURANCE INFORMATION
(Please give your insurance card to the receptionist.)
Person responsible for bill:
Birth date:
Address (if different):
Home phone no.:
/
/
(
)
 Yes
 No
Is this person a patient here?
Occupation:
Employer:
Employer address:
Employer phone no.:
(
)
Is this patient covered by
 Yes
 No
insurance?
 Blue Cross/Blue
Please indicate primary
 Carefirst
 Cigna
insurance
Shield
 Medicare
 Medicaid
 Tricare
 Other
Subscriber’s name:
Subscriber’s S.S. no.:
Birth date:
Group no.:
Policy no.:
Co-payment:
/
/
$
 Self
 Spouse
 Child
 Other
Patient’s relationship to subscriber:
Name of secondary insurance (if applicable):
Subscriber’s name:
Group no.:
Policy no.:
 Self
 Spouse
 Child
 Other
Patient’s relationship to subscriber:
IN CASE OF EMERGENCY
Name of local friend or relative (not living at same address):
Relationship to patient:
Home phone no.:
Work 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 The Center for integrative healthcare or insurance company to release any
information required to process my claims.
Patient/Guardian signature
Date

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