Primary Health Solutions-Patient Registration Form

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PRIMARY HEALTH SOLUTIONS
PATIENT REGISTRATION FORM
PATIENT INFORMATION:
Last Name
First Name
MI
Nickname
Social Security #
Birth Date
Sex
Patient Billing Address (Responsible Party)
City
State
Zip
Patient Residence (if different)
City
State
Zip
RESPONSIBLE PARTY (Required for patients less than 18 and whenever the guarantor is not the patient):
Last Name
First Name
MI
Social Security #
Birth Date
Relationship
INSURANCE INFORMATION (Please present ALL Insurance Cards and a Picture ID to the receptionist):
Primary Insurance
Policy #
Group #
Effective
Co-Pay
Policy Holder
Relationship
Secondary Insurance
Policy #
Group #
Effective
Co-Pay
Policy Holder
Relationship
Tertiary Insurance
Policy #
Group #
Effective
Co-Pay
Policy Holder
Relationship
STATISTICS REQUIRED FOR GOVERNMENTAL REPORTING PRIMARY CARE AND PRIMARY DENTAL PROVIDERS:
Please
Race: G White
G Black/African-American
G American Indian
G Asian
G Hawaiian
G Pacific Island
G More than one race
G Other
Please
Ethnicity: G Hispanic or Latino
G Not Hispanic or Latino
G Unknown/Not Reported
Please
to indicate the languages you can speak fluently:
G English
G Spanish
G French
G German
G Russian
G Other: _____________________________
Do you speak English fluently? G Yes
G No
If no, preferred language: ___________________________________
Please
LL that apply:
G Visually Impaired
G Hearing Impaired
G Language Barrier
G Veteran
G Smoker
G Homeless
G Migrant Farm Worker
Please
your Religion: G Christian
G Agnostic
G Atheist
G Buddhist
G Jewish
G Hindu
G Islamic
G Pentecostal
G Scientologist
G Other
Please
Tax Filing Status:
G Return Not Filed
G Single
G Married
G Head of Household
If you
Head of Household, please indicate if the Head of Household is a:
G Male
G Female
Please
Marital Status:
G Single
G Married
G Widowed
G Legally Separated
G Divorced
G Life Partner
G Other
Please
Student Status:
G Full-time Student
G Part-time Student
CONTACT PREFERENCES:
to indicate the method of contacting preferred: G Home (
) ______________ G Day/Work (
) ______________
G Cell/Alternate (
) ________________ G E-mail _____________________________________
Emergency contact name
and numbers
ADVANCED DIRECTIVE:
Do you have a living will? G Yes
G No
If YES, at which hospital is it filed? ________________________________

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