Medical Registration Form printable pdf download

Loudoun Walk In Medical Center

vers 1 dated 24Sep2010

44320 Premier Plaza – Suite 120, Ashburn, VA 20147

Tel: (703) 726-9056; Fax: (703) 726-9058

Account #:

REGISTRATION SHEET

NAME:_______________________________________________________________________________

(FIRST)

(MI)

(LAST)

ADDRESS:____________________________________________________________________________

(STREET)

______________________________________________________________________________________

(CITY)

(STATE)

(ZIP)

HOME TEL: (

)________________________ WORK TEL: (

)___________________________

LOCAL TEL: (

)______________________ E-MAIL ADDRESS:___________________________

(IF DIFFERENT FROM HOME TEL.)

DATE OF BIRTH:___________________

SS #:____________________________________________

(MONTH/DATE/YEAR)

SEX:

F / M

MARITAL STATUS:

Single/Married/Separated/Divorced/Widowed

EMPLOYER/SCHOOL:__________________________________________________________________

ADDRESS:____________________________________________________________________________

(STREET)

(CITY)

(STATE)

(ZIP)

PRIMARY INSURANCE CARRIER:____________________________________________________

INSURED’S NAME:_____________________________________________________________________

(FIRST)

(MI)

(LAST)

SOCIAL SECURITY #:_________________________________ BIRTH DATE:____________________

PATIENT’S RELATIONSHIP TO INSURED:________________________________________________

INSURED’S EMPLOYER:________________________________________________________________

SECONDARY INSURANCE CARRIER:___________________________________________________

INSURED’S NAME:______________________________________________________________

SOCIAL SECURITY #_________________________________BIRTH DATE_____________________

PATIENT’S RELATIONSHIP TO INSURED:_______________________________________________

NEXT OF KIN:_________________________________________________________________________

(FIRST)

(MI)

(LAST)

ADDRESS:_______________________________________________________________ ZIP_________

(STREET)

(CITY)

SOCIAL SECURITY #:_________________________ HOME TEL: (

)________________________

Authorization/ Assignment/ Responsibility Statement

I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES FOR SERVICES RECEIVED,

INCLUDING, BUT NOT LIMITED TO, THE BALANCE REMAINING AFTER PAYMENT OF POSSIBLE INSURANCE

BENEFITS AND ANY NON-COVERED SERVICES BY MY INSURANCE COMPANY. I AUTHORIZE PAYMENT OF

MEDICAL BENEFITS FOR MYSELF TO LOUDOUN WALK IN MEDICAL CENTER AND AUTHORIZE THE RELEASE OF

ANY MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM. I AGREE TO PAY COLLECTION COSTS AND

REASONABLE ATTORNEY FEES INCURRED IN ATTEMPTING TO COLLECT ON ANY OUTSTANDING BALANCES ON

MY ACCOUNT.

Signed___________________________________________ Date______________________________

(Patient/Parent/Guardian/Next of Kin)

(M/D/Y)

Medical Registration Form

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