Patient Registration Form - Wayne Memorial Community Health Centers

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WAYNE MEMORIAL COMMUNITY HEALTH CENTERS
DATE _____________ FIRST NAME _________________________MIDDLE ________ LAST NAME ____________________________
DATE OF BIRTH ____________________
MARITAL STATUS: _______________ PRIOR LAST NAME _______________________
ADDRESS:
_______ _______________________
HOME PHONE: _______________________________
CELL PHONE:
_______
EMAIL: __________________________________________________
ALTERNATE PHONE: ________________________________
CONTACT BY: Circle One: Home Phone Cell Phone Email
SEX : M
F SOCIAL SECURITY # _____________________ ____
PERSON TO NOTIFY IN CASE OF EMERGENCY ______________________________________ TELEPHONE # ____________________
FAMILY (PRIMARY CARE) PHYSICIAN: ________________________________________________________________________________
HOW WERE YOU REFERRED TO OUR OFFICE:__________________________________________________________________________
IF MINOR CHILD – NAME OF PARENT OR GUARDIAN:
_______
* GUARANTOR IS THE PERSON FINANCIALY RESPONSIBLE FOR BALANCES. IF OTHER THAN THE PATIENT PLEASE
PROVIDE REQUIRED INFORMATION- GUARANTOR IS:
PATIENT
OTHER ________________________________________
ADDRESS; ______________________________________________________________________DATE OF BIRTH ____________________
SOCIAL SECURITY #_____________________________________ TELEPHONE # OF GUARANTOR: ____________________________
INSURANCE INFORMATION-PLEASE PROVIDE CARD
PATIENT WILL BE CONSIDERED A SELF-PAY ACCOUNT UNTIL INFORMATION IS PROVIDED
PRIMARY INSURANCE: ____________________________________________________________ __________________
INSURANCE ADDRESS: ________________________________________________________________________________
PRIMARY INSURANCE HOLDER INFORMATION:
INSURED IS :
PATIENT
OTHER
INSURANCE ID# ______________________________________________________________________________________
GROUP ID# ______________________________________________________________
NAME OF INSURED (POLICY HOLDER): _______________________________________________________________
POLICYHOLDER DATE OF BIRTH: _____________________ RELATIONSHIP TO PATIENT __________________
ADDRESS OF INSURED: _______________________________________________________________________________
TELEPHONE NUMBER OF INSURED: ___________________________________________________________________
SOCIAL SECURITY NUMBER OF INSURED: _____________________________________________________________
SECONDARY INSURANCE: ____________________________________________________________ __________________
INSURANCE ADDRESS ________________________________________________________________________________
SECONDARY INSURANCE HOLDER INFORMATION:
INSURED IS:
PATIENT
OTHER
INSURANCE ID# ______________________________________________________________________________________
GROUP ID# ______________________________________________________________
NAME OF INSURED (POLICY HOLDER) : _______________________________________________________________
POLICYHOLDER DATE OF BIRTH: _____________________ RELATIONSHIP TO PATIENT __________________
ADDRESS OF INSURED: _______________________________________________________________________________
TELEPHONE NUMBER OF INSURED: ___________________________________________________________________
SOCIAL SECURITY NUMBER OF INSURED: _____________________________________________________________
PHARMACY PREFERENCE __________________________ CITY/STATE ____________________________________________
I undersigned, hereby CONSENT TO TREATMENT and grant permission to release my medical information and to authorize payment of
health insurance benefits to the above-named doctor(s). I also understand that I am fully responsible for payment of deductibles and co-
insurance and any charges that are incurred and not covered by my health insurance.
Signature:
Date:
PAYMENT: We accept cash, checks and credit cards. Payment is due upon receipt of medical services. Co-payments must be paid at the
time of your visit. If financial arrangements are needed, please notify the receptionist, as approval will be needed before your visit.
J:\FORMS\CHC's - Phys Billing\CHC SHARED FILES BETWEEN ALL OFFICES\PATIENT REGISTRATION FORM TEMPLATE 7 30 15.doc

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