Registration-Change Of Information Form
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1Premier Family Medicine, LLC
Registration &
Cathy Yoder, MD
Change of Information Form
Mike Summitt, PA-C
Courtney Sullenberger, PA-C
Please NOTE: All questions are important. We only ask what we need to know or what is required by the
Complete ALL boxes, writing “n/a” in a box that is not applicable.
Federal Government.
First Name
Middle
Last Name
Suffix
Salutation
Jr Sr III ____ n/a
Mr Mrs Ms Dr _______
Date of Birth
Gender
Social Security #
Marital Status
F
M
Single
Married __________
Street Address
City, State ZIP
Email Address (to activate your patient portal account)
Language Preference* (note: staff only speaks English)
English
Spanish
________________________
Home Phone
Cell Phone (accept text? Yes No)
Work Phone
Contact Preference
Email
Home Phone
Cell Phone
Work Phone
Race (census bureau category)*
Ethnicity*
Emergency Contact Name, Relationship, Telephone
White
Black or African American
Not-Hispanic
White Hispanic
Black Hispanic
Hispanic or Latino
Unknown
Other ___________________
*Race, Ethnicity & Language Preference, have no impact on your care but we are required by the Federal Government & Meaningful Use to ask.
Other Immediate Family Members seen at Premier Family Medicine : (spouses & minor children living at the same address)
Name: __________________________ M/F DOB: _________
Name: __________________________ M/F DOB: ________
Name: __________________________ M/F DOB: _________
Name: __________________________ M/F DOB: ________
Name: __________________________ M/F DOB: _________
Name: __________________________ M/F DOB: ________
Responsible Party (Guarantor):
Patient Relationship
Printed Name of Guarantor: (if not Self)
Date of Birth: (if not Self)
Self
Spouse
to Guarantor:
Child
Other
Street Address (if different from Patient)
City, State ZIP
Telephone: (if different from Patient)
Authorization to Release Information for Payment, Assignment of Benefits & Acceptance of Financial Responsibility:
I authorize the release of any information regarding services rendered at Premier Family Medicine to the responsible insurance
carrier(s) and for Medicare related claims to the Social Security Administration, its intermediaries, carriers, or fiscal agents. I permit
a copy of this authorization to be used in place of the original, or the statement, “Signature on File” to be printed on claims and
request payment of medical insurance benefits be made directly to the provider.
As the Patient or the Patient’s Guardian, I understand and agree that I am financially responsible for my healthcare and accept
responsibility for all charges not paid directly by my insurance carrier(s).
Signature:________________________________________________________________Date:___________________________
Your signature is necessary for us to file claims on your behalf.
v07232015
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