Patient Registration & Insurance Information Form
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1
2Patient Registration & Insurance Information
Please present insurance card and photo ID for us to copy.
Date ________________________________ Physician ________________________________________
Person Responsible
Guarantor Name _______________________________________________________________________________
for Bill
Address _______________________________________________________________________________________
City, State, ZIP _________________________________________________________________________________
Home Phone # ___________________________________ Work Phone # ________________________________
Relation to Patient _________________________________
Patient Information
Name ________________________________________________________________________________________
Address _______________________________________________________________________________________
City, State, ZIP __________________________________________________________________________________
Home Phone # ___________________________________ Work Phone # ________________________________
Cell Phone # _____________________________________ Email ________________________________________
Date of Birth _____________________________________ Sex ___________ Marital Status __________________
Race:
Black, African American
Asian
White
American Indian, Alaska Native
o
o
o
o
o
Native Hawaiian, Other Pacific Islander
o
Unknown
o
Declined
Ethnicity:
Hispanic or Latino
Not-Hispanic or Latino
Unknown
Declined
o
o
o
o
Primary Language
____________________________________________
Social Security Number ____________________________________________
(If a minor): Mother’s Name_______________________________________ Home Phone #__________________
Father’s Name _______________________________________ Home Phone #__________________
Emergency Contact
Contact Name _________________________________________________________________________________
Information
Relationship to Patient ____________________________________________________________________________
Address _______________________________________________________________________________________
City, State, ZIP _________________________________________________________________________________
Home Phone # ___________________________________ Work Phone #_________________________________
Primary
Insurance Name ________________________________________________________________________________
Insurance Name
Group #________________________________________ Policy # ______________________________________
Subscriber Name _______________________________________________________________________________
Patient Relation to Subscriber ___________________________________ Date of Birth _______________________
Social Security Number _______________________________________
Employer _______________________________________________ Work Phone # _________________________
Secondary
Insurance Name ________________________________________________________________________________
Insurance Name
Group #________________________________________ Policy # ______________________________________
Subscriber Name _______________________________________________________________________________
Patient Relation to Subscriber ___________________________________ Date of Birth _______________________
Social Security Number _______________________________________
Employer _______________________________________________ Work Phone # _________________________
Referred by ________________________________________________
02/2013
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Parent category: Medical