Patient Registration Form - Maine Medical Center Page 2

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ACCIDENT INFORMATION
Are these services today the result of an accident:
Yes
No
If “Yes”, please provide the following information:
What type of accident caused the illness/injury:
Automobile
Work Related
Crime Victim
Other Accident
If automobile accident, which type of accident:
No Fault
Liability
Recreational Vehicle
Date of Accident: ____________________________ Location: ______________________________ Nature: ______________________________
Name of Insurance Company: _______________________________________ Telephone Number: Area code (
) _______________________
Name of Insured (Policy Holder): __________________________________ Policy Holder’s Relation to Patient: ____________________________
Policy Number: __________________________________ Group Name: ________________________________________
Policy Holder’s Employer: _____________________________________ Employer’s Phone Number: Area code (
) _____________________
Insurance Company Address: _________________________________ City _________________________ State _____________ Zip Code_______
INSURANCE INFORMATION
Medicare:
HIC #: ____________________________ Is patient entitled to Medicare based on:
Age
Disability
End Stage Renal Disease
Part A (Hospital) Effective Date: _____________________________ Part B (Medical) Effective Date: ____________________________
Does patient have a Medicare Replacement / Medicare HMO product?
Yes
No
If yes, please provide: Product Name: ____________________________________Telephone Number: Area code (
) ____________________
Billing Address: ______________________________ City __________________________ State ________________ Zip Code________
Policy Number: _______________________________________ Group Number: _______________________________________
Are services covered by Federal Black Lung Program:
Yes
No
Are services covered by research grant:
Yes
No
Is patient undergoing dialysis?
Yes
No If Yes, please list the date dialysis began: _____________________
Has patient had a kidney transplant?
Yes
No If Yes, please list the date: _____________________
Does patient have Group Health Insurance based on their own or spouse’s current employment:
Yes
No
If yes, does the employer that sponsors the Group Health Insurance Employ:
20 or more employees
100 or more employees
NA
If patient is retired, please list the retirement date: ______________________________
Tricare:
Which Tricare Plan:
Tricare Standard
Tricare Prime
Tricare for Life
Sponsor’s Name: ________________________ Sponsor’s Social Security Number: __________________Sponsor’s Date of Birth: _____________
Branch of Service: ___________________________ Policy Number: ____________________________ Status:
Active
Retired
Deceased
Other Insurances:
st
1
insurance to bill: Does insurance card include one of these logos:
First Health
PHCS
Name of Insurance Company: _______________________________________ Telephone Number: Area code (
) _______________________
Insurance Company Address: _________________________________ City _________________________ State _____________ Zip Code_______
Name of Insured (Policy Holder): __________________________________ Policy Holder’s Relation to Patient: ____________________________
Policy Number: _______________________________________ Group Number: _______________________________________
Policy Holder’s Social Security Number: _____________________________ Policy Holder’s Employer: ___________________________________
nd
2
insurance to bill: Does insurance card include one of these logos:
First Health
PHCS
Name of Insurance Company: _______________________________________ Telephone Number: Area code (
) _______________________
Insurance Company Address: _________________________________ City _________________________ State _____________ Zip Code_______
Name of Insured (Policy Holder): __________________________________ Policy Holder’s Relation to Patient: ____________________________
Policy Number: _______________________________________ Group Number: _______________________________________
Policy Holder’s Social Security Number: _____________________________ Policy Holder’s Employer: ___________________________________
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PHYSICIAN’S OFFICE USE ONLY - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Did patient/representative sign written acknowledgement receipt of the notice of HIPAA:
Yes
No
Refused
Unavailable/Emergency
If yes, please listed the date acknowledgement was signed: _____________________________
Database Code: __________________________
142306+ 7/10 107246
NOT A MEDICAL RECORD

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