Hipaa Registration Form Guarantor Information

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HIPAA Registration Form
Last Name: ________________________________
First Name: _______________________________________ Middle Initial: __________
Preferred Name (if applicable): ________________________________
Status:
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Child
Single
Married
Widowed
Separated
Divorced
Street Address: ___________________________________________ Apt# ______ City: ________________ State: ______ Zip: ______ County:
________
Date of Birth: ___________ / ___________ / ___________ Sex:
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Male
Female
Social Security Number: ___________ - ________ -
___________
Race:
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American Indian / Native Alaskan
Asian
Black/African American
Hispanic/Latino Native
Hawaiian/Pacific Islander
White
Other
Home Phone: ( _______ ) ____________________ Work Phone: ( _______ ) ____________________ Cell Phone: ( _______ )
____________________
Email Address: _____________________________________________________________
Emergency Contact: ______________________________ Phone Number: ( _______ ) ______________ Relationship to Patient:
______________________
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Primary Insurance: _____________________________________ Secondary Insurance: __________________________________ No Insurance
Subscriber: ___________________________ Relationship: _____________ Subscriber: ___________________________ Relationship:
_____________
Gender:
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Male
Female Date of Birth: ________ / ________ / _______ Social Security Number: ___________ - ________ - ___________
Gender:
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Male
Female Date of Birth: ________ / ________ / _______ Social Security Number: ___________ - ________ - ___________
Occupation: _____________________________________________
Employer (or School if student):__________________________
________________
How were you referred to us?:
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Family/Friend
Physician
Internet
Insurance
Newspaper
Phone Book
Radio
Walk-In
Other
If personally referred, whom may we thank for the referral? ________________________________________________________________________
Guarantor Information (If patient is a Minor or Dependent)
Last Name: ________________________________
First Name: _______________________________________ Middle Initial: __________
Street Address: ___________________________________________ Apt# ______ City: ________________ State: ______ Zip: ______ County:
________

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