Western Washington Medical Group Department Of Urology - Registration Form

WESTERN WASHINGTON MEDICAL GROUP

REGISTRATION FORM

DEPARTMENT OF UROLOGY

ACCOUNT#___________________

NEW

_____ UPDATE

______

PATIENT LAST NAME

FIRST NAME (legal)

MI

PREFERRED OR NICKNAME

DATE OF BIRTH

SEX

RACE

SOCIAL SECURITY #

M

F

ETHNICITY

PREFERRED LANGUAGE

MAILING ADDRESS

APT #

CITY

STATE

ZIP CODE

4 DIGIT

STREET ADDRESS

APT #

CITY

STATE

ZIP CODE

4 DIGIT

HOME PHONE

WORK PHONE

EXT

CELL PHONE

(

)

(

)

(

)

REFERRING DOCTOR

MARITAL STATUS

MARRIED _____

DIVORCED _____

OTHER

_____

PRIMARY CARE DOCTOR

SINGLE

_____

WIDOWED _____

SEPARATED

_____

PHARMACY NAME, PHONE NUMBER AND LOCATION

PREFERRED EMAIL ADDRESS

PATIENT EMPLOYER (IF NOT EMPLOYED ARE YOU RETIRED_____ OR DISABLED_____)

EMPLOYER NAME

OCCUPATION

STREET ADDRESS

CITY

STATE

ZIP CODE

4 DIGIT

PRIMARY INSURANCE

INSURANCE COMPANY NAME

RELATION TO SUBSCRIBER

COPAY

SUBSCRIBER'S NAME

SUBSCRIBERS EMPLOYER

SUBSCRIBERS DATE OF BIRTH

SUBSCRIBER'S SEX

SUBSCRIBERS ID #

GROUP NUMBER

MALE ___

FEMALE ___

SECONDARY INSURANCE

INSURANCE COMPANY NAME

RELATION TO SUBSCRIBER

COPAY

SUBSCRIBER'S NAME

SUBSCRIBERS EMPLOYER

SUBSCRIBER'S DATE OF BIRTH

SUBSCRIBERS SEX

SUBSCRIBERS ID #

GROUP NUMBER

MALE ___

FEMALE ___

EMERGENCY CONTACT

NAME

RELATIONSHIP

PHONE NUMBER- HOME/WORK/CELL

( NOT LIVING WITH YOU )

(

)

RESPONSIBLE PARTY

WHO IS RESPONSIBLE FOR THE REMAINING BALANCE ON THIS ACCOUNT?

_____ SELF

SOCIAL SECURITY #

LAST NAME

FIRST NAME

MI

(* If self do not fill in right field.)

_____ SPOUSE

STREET ADDRESS

CITY

STATE

ZIP CODE

4 DIGIT

_____ PARENT

_____ GUARDIAN

HOME PHONE

WORK OR CELL PHONE

EXT

DATE OF BIRTH

SEX

(

)

(

)

M

F

WORKERS COMP CLAIM #

DATE OF INJURY

EMPLOYER

STATE OR SELF INSURED?

I, the patient or guardian, certify that the information contained on this form is true to the best of my knowledge. I accept responsibility for the charges incurred by the patient,

and agree to pay all bills at the time of service, unless prior arrangements have been made. I authorize the physician and clinic to release any information to process insurance

claims. I authorize my insurance claim to be paid directly to the clinic. I authorize Western Washington Medical Group to leave messages, which may contain details of my

medical condition on my voicemail box if they are unable to reach me.

INITIALS

VOICEMAIL #

PATIENT SIGNATURE

DATE

For office use only

Initials ______

Dr.______________________

Ins. code___________________________

Acct # ______________________________

Patient Registration for GE 021012.xls