Form Mr-003 - Patient Registration - Insurance Form
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1
2Peterkort Clinic
Tualatin
9555 SW Barnes Road, Suite 301
19260 SW 65th Avenue, Suite 340
Portland, OR 97225
Tualatin, OR 97062
Ph: (503) 297-3371 Fax: (503) 297-7975
Ph: (503) 691-9777 Fax: (503) 692-6736
Name (Last, First MI): _______________________________________________ Name patient likes to be called: ___________________________
Date of Birth: _____ / _____ / _____ Gender:
F Primary Care Physician: _________________________________________________
M
Ethnicity:
Hispanic or Latino
Decline
Non-Hispanic or Latino
African American
Race:
Caucasian
Hispanic
Pacific Islander
Asian
Native American or Alaskan
Other
Decline
Language Preference: _______________________________________________________________________
Interpreter Needed:
No
Yes
Address: _____________________________________________________________________________________________________________________
City: _______________________________________________________________________________ State: _________ Zip: _____________________
Email: ____________________________________
Phone: _________________________
Preferred method of contact (please select one):
Emergency Contact(other than parent/guardian):
___________________________________
____________________________
____________________________
_________________________
Name
Relationship to patient
Home Phone
Work Phone
Referral Source:
Friend
Coworker
Hospital/ER
Website
Family Member
Other: ________________________________
Physician Referral
Insurance Company
Medicaid
Internet Search
If you were referred by a current patient of TCC, please let us know their name so we may send them a “thank you” gift.
Parent/Patient Referral Name: __________________________________________________________________________________________________
Parent 1: ____________________________________________________
Parent 2: ____________________________________________________
Last
First
MI
Last
First
MI
Date of Birth: _______ / _______ / _______
Date of Birth: _______ / _______ / _______
SSN: _______________________________________________________
SSN: _______________________________________________________
Address:
Same as patient
Address:
Same as patient
_____________________________________________________________
____________________________________________________________
_____________________________________________________________
____________________________________________________________
City
State
Zip
City
State
Zip
Home Phone: ________________________________________________
Home Phone: _______________________________________________
Cell Phone: _________________________________________________
Cell Phone: _________________________________________________
Email: ______________________________________________________
Email: ______________________________________________________
Employer: __________________________________________________
Employer: __________________________________________________
Occupation: _________________________________________________
Occupation: ________________________________________________
Primary Insurance
Secondary Insurance
_____________________________________________________________
____________________________________________________________
Insurance Company
Insurance Company
_____________________________________________________________
____________________________________________________________
Claim Address
Claim Address
_____________________________________________________________
____________________________________________________________
Phone Number
Phone Number
Subscriber: _________________________________________________
Subscriber: _________________________________________________
Subscriber Address: _________________________________________
Subscriber Address: _________________________________________
_____________________________________________________________
____________________________________________________________
Subscribers Birth Date: _______ / _______ / _______
Subscribers Birth Date: _______ / _______ / _______
Relationship to Patient: ______________________________________
Relationship to Patient: ______________________________________
ID#: _________________________ Grp#: _______________________
ID#: _________________________ Grp#: _______________________
Copay: _________________ Effective Date: ______ / ______ / ______
Copay: ________________ Effective Date: ______ / ______ / ______
I hereby authorize The Children’s Clinic, P.C. to provide medical services to the above named patient and to use and release medical information as
required for treatment, payment and health care operations. I authorize The Children’s Clinic to recognize me as a participant of the Patient-Centered
Primary Care Home Program*. I also assign The Children’s Clinic all payments to which I am entitled for medical and surgical expenses. I understand
that I am financially responsible for all charges whether covered by insurance or not. I understand insurance copays are due at time of service. I have
received a copy of the current Privacy Notice of The Children’s Clinic.
Signature: __________________________________________________________________________________________ Date __________________________
*For additional information on the Patient-Centered Primary Care Home Program, please see any staff member.
PLEASE BE SURE TO COMPLETE THE OTHER SIDE OF THIS FORM.
MR-003 (1/13)
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Parent category: Medical