Patient Registration Information And Pet/ct Worksheet printable pdf download

REGISTRATION INFORMATION

PATIENT INFORMATION (PLEASE USE FULL LEGAL NAME)

Last: __________________________________________ First: ________________________________________________ MI: ______________ Sex: ________________

Address: ____________________________________________________________________________________________________________________________________

City: ___________________________________________________________________________ State: _____________________ Zip: ____________________________

Home Phone: ________________________________________ Other Phone: _________________________________________ DOB: ____________________________

Social Security#: ________________________________________ Marital Status:

Married

Single

Divorced

Widowed

Employer: ____________________________________________________________________________ Job Title: _____________________________________________

Employer Address: _____________________________________________________________Work Phone: _________________________________________________

Emergency Contact Name: ___________________________________________________________________________________________________________________

Emergency Contact Phone number: ______________________________________________________________________________________________________________

RESPONSIBLE PARTY INFORMATION

Last: ___________________________________ First: _____________________________ Relationship to Patient: __________________________________________

Address: ________________________________________________________________________________Social Security #: ___________________________________

DOB: _______________________________________________ Employer: ______________________________________________________________________________

Employer Address: __________________________________________________________________Phone Number___________________________________________

INSURANCE INFORMATION

On the job injury:___________________

Motor Vehicle Accident: ___________________

Primary Insurance

Insurance Company:_________________________________ Address: _______________________________________________________________________________

City: _______________________________________________ State: _____________ Zip: _____________________ Phone: __________________________________

Policy Holder: _________________________________ Policy #: ___________________________________ Group Number: _________________________________

Adjuster: _____________________________________________________________________________________________________________________________________

Secondary Insurance

Insurance Company:_________________________________ Address: _______________________________________________________________________________

City: _______________________________________________ State: _____________ Zip: _____________________ Phone: __________________________________

Policy Holder: _________________________________ Policy #: ___________________________________ Group Number: _________________________________

RELEASE OF INFORMATION AND PAYMENT AUTHORIZATION

I authorize the release of information necessary to process this claim and assign benefits payable for services directly to Envision Imaging.

I authorize the release of any medical information necessary for treatment by my current or future physician or healthcare provider. I

authorize Envision Imaging to release to my insurance company any medical information which may be necessary to process my

insurance claim. I understand that in the event my insurance company denies this claim I will be held financially responsible for all

charges. I acknowledge that I have received a copy of Envision Imaging's Privacy Notice.

Initials __________________

Signed: ______________________________________________________________________________ Date: _________________________________________________

Patient Registration Information And Pet/ct Worksheet