Patient Registration/patient Insurance Form
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1
2LEXINGTON CLINIC
Patient Registration Form
ACCOUNT/MRN: ____________________________
Date: _____________________________
PATIENT DEMOGRAPHIC INFORMATION
Name:
Address:
Apt. / Suite:
City:
_____
State:
Zip:
____ Country Code: _________
Home Phone: (
)
Cell Phone: (
) ________________ Email Address: _____________________
Birth Date:
__________
Sex:
Male
Female SS#:
_______________
Marital Status: ___Single
___ Married ___ Divorced ___ Widowed
Primary Care Physician: ___________________
Emergency Contact Name: _____________________ Relationship: __________
Phone: (
)
_____
Race: ___Caucasian ___African-American ___Hispanic ___ Asian/ Pacific Islander ___American Indian/Alaskan Native
____Other Ethnicity: ___ Hispanic ___ Non Hispanic Primary Language: __________________
Employer:
Address:
City: __________________________________
State: _____________
Zip: __________________
Work Phone:
(
)
RESPONSIBLE PARTY BILLING INFORMATION
Name:
Address:
Apt. / Suite:
City:
State:
Zip:
Phone: (
)
INSURANCE INFORMATION
Primary Insurance
PRIMARY INSURANCE
Insurance Name:
I.D. #:
Group #:
Effective Date:
Address:
City/State/Zip:
Phone:
(
)
Subscriber Name:
Relationship to Patient:
Address:
City/State/Zip:
Birth Date:
Sex: _
Male
Female
Soc. Sec. #:
Employer Name:
Address:
City/State/Zip:
Secondary Insurance
Insurance Name:
I.D. #:
Group #:
Effective Date:
Address:
City/State/Zip:
Phone:
(
)
Subscriber Name:
Relationship to Patient:
Address:
City/State/Zip:
Birth Date:
Sex: _____Male
Female
Soc. Sec. #:
Employer Name:
Address:
City/State/Zip:
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Parent category: Medical