Patient Registration Information Form
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1
2Patient Registration Information for Consumer Number
:_____________________
Thank you for choosing Group Health Cooperative as your health care provider. By completing the following information we will be able to
maintain accurate information which will assist us in providing quality services to you and your family.
PATIENT DEMOGRAPHIC INFORMATION
Patient Name: _________________________________
Previous Last Name: ____________________
Mailing Address: ___________________________________________
City: _______________________
State: ____
Zip Code: __________
Night Phone: ______________
Day Phone: ______________
Sex: _______ Birthdate: __________
Social Security #: _____________________
Marital Status:
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Domestic Partner
Divorced
Married
Single
Widowed
Legally Separated
═════════════════════════════════════════════════════════════════
PATIENT EMPLOYER INFORMATION
: _____________________________________
Employer Name
(please include parent company name if applicable)
Mailing Address: ___________________________________________
City: ______________________
State: ______
Zip Code: __________
Your Occupation: __________________________
Employer Phone: _____________
Your Employment Status:
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Full time
Part time
Not Employed
Retired
Self Employed
Active Military
═════════════════════════════════════════════════════════════════
LEGAL NEXT OF KIN (EMERGENCY CONTACT or OTHER)
Relation to Patient: __________________ Name: _________________________________
Mailing Address: ___________________________________________
City: _______________________
State: ____
Zip Code: __________
Night Phone: ______________
Day Phone: ______________
═════════════════════════════════════════════════════════════════
ALTERNATE CONTACT (EMERGENCY CONTACT)
Relation to Patient: __________________ Name: _________________________________
Mailing Address: ___________________________________________
City: _______________________
State: ____
Zip Code: __________
Night Phone: ______________
Day Phone: ______________
════════════════════════════════════════════════════════════════════════════════
FINANCIALLY RESPONSIBLE PARTY IF OTHER THAN PATIENT (For Example: Spouse/Partner/Parent)
Name: _________________________________
Previous Last Name: ____________________
Birthdate: __________
Relationship to Patient: ________________________________
: ______________________________________
Employer Name
(please include parent company name if applicable)
Mailing Address: ___________________________________________
City: _______________________
State: ______ Zip Code: __________ Occupation: __________________________ Phone: ____________
Employment Status:
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Full time
Part time
Not Employed
Retired
Self Employed
Active Military
CONTINUED ON BACK OF FORM
45222_2007044_Patient Registration
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Parent category: Medical