Patient Registration Information Form printable pdf download

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Fax (501) 778-1013

Ph (501) 778-0934

Please check one:

Preferred Physician:

 New patient

 Update name

 Cooper

 Watson  Cathcart

Patient Registration Information

 Update address

 Previous form

 Albey

 Wright

 Barker

 Update insurance

 Dixon

 Morgan

out of date

Patient’s Personal Information

Name: _________________________________________

SS#: ____ - ____ -_____ DL#: _________________

Last

First

Marital Status: S / M / D / W

Date of Birth: __ / __ / ____

Sex: M / F

Main phone#: (___)______________

Alternate phone: (___)______________ E-mail:_____________________________________________________

Address: ______________________________ Apt#: ______ City: _____________ State:_______ Zip:_________

Employer:_________________________ Work phone: (___)_______________ Occupation:__________________

Employer Address:___________________________________ City:__________ State:___________ Zip:________

 White

 African American

 Asian

 Other

 Not Hispanic/ Latino

 English

Race:

Ethnic Group:

Primary Language:

 Hispanic/Latino

 Native American Indian/Alaskan  Decline to answer

 Spanish

 Native Hawaiian/Other Pacific Islander

 Decline to answer

 Other

Emergency Contact—

Preferred Pharmacy

Please list someone that does not live with you

Name:___________________________ Relationship:______________________

Name: ____________________

Best Phone: (___)_______________ Alternate Phone: (___)_________________

Phone #:___________________

If self, do not complete this section.

Guarantor Information

Relationship to patient:  Self

 Spouse

 Father

 Mother

 Other____________

Name: _________________________________________

SS#: ____ - ____ -_____ DL#: ________________

Last

First

Date of Birth: ___ / ___ / ____ Main phone#: (___)_______________ Alternate phone: (___)_____________

Address: ______________________________ Apt#: ______ City: _____________ State:______ Zip:_________

Employer:_________________________ Work phone: (___)_______________ Occupation:__________________

Patient’s Insurance Information

Primary Insurance Company Name: __________________________________ ID#: _________________________

Group#: _______________________ Insurance Address: ______________________________________________

Subscriber Name: _________________________ Date of Birth: ___ / ___ / ____ Main phone#: (___)_________

 Self  Spouse  Father  Mother  Other________ Copay: $________

Subscriber’s relationship to patient:

Secondary Insurance Company Name: __________________________________ ID#: _______________________

Group#: _______________________ Insurance Address: ______________________________________________

Subscriber Name: _________________________ Date of Birth: ___ / ___ / ____ Main phone#: (___)_________

 Self  Spouse  Father  Mother  Other________ Copay: $________

Subscriber’s relationship to patient:

I request that payment of authorized insurance benefits be made on my behalf to the provider indicated above for services furnished me. I authorize any

holder of medical information about me or my dependent to release to the insurance company any information needed to determine these benefits or the

benefits payable for related services. A photocopy of this assignment is to be considered as the original. I understand that I am financially responsible for

all charges whether or not covered by said insurance. This assignment will remain in effect until revoked by me in writing. I further agree to pay the cost of

collection, court costs, and other reasonable fees should they be required in the event of my non-payment. (If this patient is a minor child, the parent

signing this form will be financially responsible for the child. Any legal agreement, or other disagreement, between parents in a divorce must be dealt with

between those parties and does not involve Family Practice Associates.)

_____________________________________

_____________________

Signature (of Guarantor, if patient is minor)

Date