Patient Registration Form
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1Patient Registration
PATIENT INFORMATION
(Please Print)
Name:
Sex:
Male
Female
Address:
Date of Birth:
Age:
________
Social Security #:
___________________________________
City, State, Zip:
Driver’s License/ID #:
_______________________________
Race:
Ethnicity:
Hispanic or Latino
___________________________________________
Language:
Not Hispanic or Latino
______________________________________
Email address:
Unknown / Not Reported
__________________________________
Marital Status:
Married
Single
Divorced
Primary Phone:
Home
Work
Cell
Other:
_______________
Primary Physician:
Employer:
__________________________________________
Address:
Address:
____________________________________________
Phone:
Phone:
______________________________________________
Date of injury or onset of symptoms:
Was this an injury?
Yes
No
Where did your injury occur?
Work
Auto
Home
School
Other:
__________________________________
Who referred you to us/How did you hear about us?
_____________________________________________________
GUARANTOR RESPONSIBLE PARTY
Patient
Other:
Relationship:
Name:
Employer:
__________________________________________
Address:
Phone:
______________________________________________
Social Security #:
___________________________________
City, State, Zip:
Date of Birth:
_________________________________
_______________________________________
PRIMARY INSURANCE
Insured Party:
Patient
Guarantor
Other:
Insured’s Name:
Social Security #:
Insurance Carrier:
Date of Birth:
Claims Address:
Insured ID/Cert #:
City, State, Zip:
Group #:
____________________________________________
Phone:
SECONDARY INSURANCE
Insured Party:
Patient
Guarantor
Other:
Insured’s Name:
Social Security #:
Insurance Carrier:
Date of Birth:
Claims Address:
Insured ID/Cert #:
City, State, Zip:
Group #:
____________________________________________
Phone:
EMERGENCY CONTACT
Name:
Address:
Relationship:
Phone:
I hereby assign the insurance benefits to which I am entitled, directly to ORTHOPAEDIC SPECIALTY INSTITUTE, a medical group. I understand
that I am financially responsible for all charges regardless of insurance verification, benefits and eligibility. I authorize release of medical
records and information regarding medical history that is requested by the insurance company. A photocopy of this authorization is
accepted with the same authority as original.
Photo identification and insurance cards must be presented at the time of service to enable OSI to submit claims to your insurance carrier.
Should identification and insurance cards not be presented, you will become a cash patient with payment in full due at the time of service.
This agreement will remain valid from this day forward to include all future services relating to the above patient.
Rev 05/14
SIGNATURE OF PATIENT/GUARDIAN
DATE
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Parent category: Medical