New Patient Registration Form
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8GHDE Srinivas R Panja MD
REGISTRATION FORM
(Please Print)
Today’s Date:
PCP:
PATIENT INFORMATION
Patient’s last name:
First:
Middle:
Marital status:
Mr.
Miss
Mrs.
Ms.
Single
Mar
Div
Sep
Wid
Is this your legal name?
If not, what is your legal name?
(Former name):
Birth date:
Age:
Sex:
Yes
No
M
F
Street address:
Social Security no.:
Home phone no.:
(
)
P.O. box:
City:
State:
ZIP Code:
Occupation:
Employer:
Employer phone no.:
(
)
Chose clinic because/referred to clinic by (Please check one box):
Dr.
Insurance plan
Hospital
Family
Friend
Close to home/work
Yellow Pages
Other
Other family members seen here:
INSURANCE INFORMATION
(Please give your insurance card to the receptionist.)
Person responsible for bill:
Birth date:
Address (if different):
Home phone no.:
(
)
Is this person a patient here?
Yes
No
Occupation:
Employer:
Employer address:
Employer phone no.:
(
)
Is this patient covered by insurance?
Yes
No
Please indicate primary insurance
MEDICARE
BCBS
AETNA
CIGNA
HUMANA
MUTUAL OF
UNITED
UMR
FIRST HEALTH NETWORK
Other
OMAHA
HEALTHCARE
Subscriber’s name:
Subscriber’s S.S. no.:
Birth date:
Group no.:
Policy no.:
Co-payment:
$
Patient’s relationship to subscriber:
Self
Spouse
Child
Other
Subscriber’s name:
Name of secondary insurance (if applicable):
Group no.:
Policy no.:
Patient’s relationship to subscriber:
Self
Spouse
Child
Other
IN CASE OF EMERGENCY
Name of local friend or relative (not living at same address):
Relationship to patient:
Home phone no.:
Work phone no.:
(
)
(
)
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I
am financially responsible for any balance. I also authorize [Name of Practice] or insurance company to release any information required to process
my claims.
Patient/Guardian signature
Date
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Parent category: Medical