Registration Form (Page 2 of 2) in pdf

ELIGIBILITY GUARANTEE FORM

I hereby certify that I am eligible for the health insurance company under the subscriber listed in my registry sheet. I also certify

that I have chosen Annadel Medical Group to provide healthcare services. I understand that, were the aforementioned statement

not true or if I were not eligible under the terms of the Subscriber’s Medical and Hospital Agreement, I’d be responsible for any

and every charge for the services rendered. Also, if the aforementioned were not true, I agree to pay completely all the services

rendered within thirty days after receiving an invoice from said medical group or doctor.

Signature _______________________________

Date______________

ASSIGNMENT OF BENEFITS

I hereby authorize that the benefit payment be made directly to ST. JOSEPH HERITAGE HEALTHCARE for services provided to

me by ANNADEL MEDICAL GROUP, and also declare that I assume responsibility for the payment of charges not covered in

this allocation. I authorize the refund of payments in excess of insurance benefits, when the coverage is subject to benefit

coordination. In the event of payment default, I hereby pledge to pay every collection cost, including reasonable legal fees.

Signature _______________________________

Date______________

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

I authorize any holder of medical information about me to release said medical information requested by insurance companies

with whom I have coverage or any public agency and its agents to determine benefits for services received or benefits for related

services.

Signature _______________________________

Date______________

NOTICE OF PRIVACY PRACTICE

HIPAA (Health Insurance Portability and Accountability Act) regulations require us to provide to you, the patient or personal

representative, a copy of our Notice of Privacy Practice and that you acknowledge with your signature that you have received

the brochure.

Initials _________

You may share health information about the patient’s condition with:

(List here the names of individuals, family members, or other relations to whom you wish to grant authorization to share medical

information.)

Signature _______________________________

Date______________

INSURANCE SUBSCRIBER INFORMATION

Thank you for providing copies of your insurance card(s). If someone other than yourself, the patient, is the insurance

subscriber, please fill in the following information (this also applies to minors whose insurance is under a

parent/guardian):

Primary Insurance Company Name _________________________________ Subscriber ID # __________________________

Subscriber’s Name __________________________________ Date of Birth ____/____/____ Relation to patient _____________

Subscriber’s Address if other than the patient’s___________________________________ Subscriber’s SS# _____-____-_____

__________________________________

Secondary Insurance Company Name ______________________________ Subscriber ID # __________________________

Subscriber’s Name __________________________________ Date of Birth ____/____/____ Relation to patient _____________

Subscriber’s Address if other than the patient’s___________________________________ Subscriber’s SS# _____-____-_____

__________________________________

Office Use:

Patient Name _______________________

MRN ______________________________

Registration Form Page 2

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