Patient Registration Form - Premier Medical Associates Page 2

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PRIMARY HEALTH INSURANCE INFORMATION
Insurance Name ____________________________________________________________________________________________
Address ____________________________________________________________________________________ Apt/Suite ______
Zip Code __________ City ______________________________________________________ State ____
Policy ID ____________________________________________________________ Group #_______________________________
Subscriber Relationship to Patient
Same
Spouse
Parent/Guardian
Other ____________________________________
If the patient is not the subscriber, please provide the following
Subscriber Last Name _______________________________________ First Name _______________________________ MI _____
Date of Birth ____/____/________ Employer _____________________________________________________________________
SECONDARY HEALTH INSURANCE INFORMATION
Insurance Name ____________________________________________________________________________________________
Address ____________________________________________________________________________________ Apt/Suite ______
Zip Code __________ City ______________________________________________________ State ____
Policy ID ____________________________________________________________ Group #_______________________________
Subscriber Relationship to Patient
Same
Spouse
Parent/Guardian
Other ____________________________________
If the patient is not the subscriber, please provide the following
Subscriber Last Name _______________________________________ First Name _______________________________ MI _____
Date of Birth ____/____/________ Employer _____________________________________________________________________
If this visit is the result of an accident, please provide the following information
Was this injury
Auto-related
Work-related
Other _________________________________________________________
Insurance Name ____________________________________________________________________________________________
Address ____________________________________________________________________________________ Apt/Suite ______
Zip Code __________ City ______________________________________________________ State ____
Claim # ______________________________________________ Date of Accident ____/____/________
Contact/Agent Last Name _____________________________________ First Name _______________________________ MI _____
Phone Number (______)______-________
For Medicare Patients
I request that payment of authorized Medicare benefits be made either to me or on my behalf to Premier Medical Associates for any services rendered to
me by them. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any
information needed to determine these benefits or the benefits payable for related services.
Signature _____________________________________________________________________________ Date _______/_______/____________
I request that payment of authorized Medigap benefits be made either to me or on my behalf to Premier Medical Associates for any services furnished to
me by them. I authorize any holder of medical information about me to release to my Medigap insurer any information needed to determine these
benefits payable for related services.
Signature _____________________________________________________________________________ Date _______/_______/____________
For All Other Patients
I authorize release of any medical or other information necessary to process claims as well as payment of medical benefits to Premier Medical
Associates.
Signature _____________________________________________________________________________ Date _______/_______/____________
HIPAA Notice of Privacy Practices
I acknowledge that I have been given a copy of this office’s Notice of Privacy Practices, which describes how my health information is used and shared.
Signature _____________________________________________________________________________ Date _______/_______/____________
If signatures are those of a representative of the patient, please provide the following:
Name ________________________________________________________________________________
Relationship ____________________________________________________________________________

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