La Red Health Center Registration Form

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LA RED HEALTH CENTER
REGISTRATION FORM
PATIENT INFORMATION
Name(First, MI, Last): ___________________________________
Are You Enrolled in CHAP? Yes [ ] No [ ]
Social Security #: _____-____-_____
Primary Language: ____________________________________
Race:
Black/Afr. Amer. [ ]
White [ ]
Native Hawaiian [ ]
Address: ____________________________________________
P.O. Box: ____________________________________________
Asian [ ]
Amer. Indian/Alaska Native [ ]
City:_________________________________________________
Other Pacific Islander [ ]
More than 1 [ ]
State:________________ Zip-Code:_______________
Ethnic Group: Hispanic/Latino [ ]
Other [ ] _______________
Home Phone #: (______) ______-________
Country of Birth: ______________________________________
Work Phone #: (______) ______-________
Emergency Contact: ___________________________________
Cell Phone #: (______) ______-________
Emergency Contact Phone #: (______) ______-________
Can We Leave You A Voice Mail Message? Yes [ ] No [ ]
Contact Relationship: ___________________________________
Marital Status: Single [ ]
Married [ ]
Divorced [ ]
Can We Leave A Voice Mail Message With Them? Yes [ ] No [ ]
Widowed [ ] separated [ ]
Are You A Veteran?
Yes [ ] No [ ]
Sex: M [ ] F [ ]
Date of Birth: _____/_____/_____ MM/DD/YY
Housing Status? Own/Rent [ ]
Homeless Shelter [ ]
Referring Physician:_____________________________________
Transitional [ ] Doubling Up [ ] Street [ ]
Other [ ]
How did you hear about La Red Health Center?
Work [ ] Radio [ ] Public Health [ ] Brochure [ ] Other [ ]______________________
EMPLOYER INFORMATION
Student [ ] Employed [ ] Self Employed [ ] Unemployed [ ] Retired [ ] Employer Address: _____________________________________
Employer: ____________________________________________
City:___________________ State:______ Zip-Code:___________
Employer Phone Number: (______) ______-________
E-Mail Address:________________________________________
INSURANCE INFORMATION
Primary Insurance: __________________________
Secondary Insurance: ________________________
Effective Date: _____/_____/_____ MM/DD/YY
Effective Date: _____/_____/_____ MM/DD/YY
Subscriber Name: ___________________________
Subscriber Name: ___________________________
Certificate #: _______________________________
Certificate #: _______________________________
Group Name: _______________________________
Group Name: ______________________________
Group #: ___________________________________
Group #: __________________________________
Policy Telephone #: (______) ______-________
Policy Telephone #: (______) ______-________
Patient’s Relationship: Self [ ] Spouse [ ] Child [ ] Other [ ]
Patient’s Relationship: Self [ ] Spouse [ ] Child [ ] Other [ ]
Subscriber’s DOB_____/_____/_____ SSN#:_____-____-_____
Subscriber’s DOB_____/_____/_____ SSN#:_____-____-_____
PARENT/ LEGAL GUARDIAN INFORMATION
If patient is under 18 years of age, please fill out:
Name(First, MI, Last): ___________________________________
Sex: M [ ] F [ ]
Date of Birth: _____/_____/_____ MM/DD/YY
Address : _____________________________________________
Home Phone #: (______) ______-________
P.O. Box: ___________________________________________
Work Phone #: (______) ______-________
City:___________________ State:______ Zip-Code:___________
Cell Phone #: (______) ______-________
Social Security #:_____-____-_____
Relationship to Child: ___________________________________
I certify that the information on this form is true to the best of my knowledge. I accept responsibility for the medical charges
incurred by the patient and agree to pay bills at the time of service unless other arrangements have been made. I authorize my
insurance claim to be paid directly to the clinic. I further understand my health insurance carrier or payer of my health benefits may
pay less than the actual bill for services, and I am ultimately responsible for any balances. I authorize my provider to release any
information necessary for my course of treatment or requested by my insurance carrier. I have been offered and/or received a copy
of the HIPAA polices of La Red Health Center.
___________________________________________
___________________________________
_____/_____/_____
Patient’s (Guardian if patient is under 18) Signature
Print
Date
Revised 03-2010

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