Patient Registration Sheet - Lebauer Allergy & Asthma

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LeBauer Medical Center
Allergy, Asthma & Sinus Care
R
S
, MD
M
A. W
, MD
R. C
V
W
, MD
ANJAN
HARMA
EG
HELAN
HRISTOPHER
AN
INKLE
PATIENT REGISTRATION SHEET
Patient Last Name__________________First Name_________________M.I.______
BIRTH DATE______________ GENDER (M/F)____________Marital Status__________
Address__________________________________________________________________
City________________________________State_____________Zip Code_____________
Email Address:__________________________________
Phone #s: H) (
)______________ C) (
)________________ W)(
)________________
PREFERRED PHONE for Us to Contact You (circle one)
Home
Cell
Work
________________
Primary Care Physician Name:__________________ Referring Physician(if any)
Preferred Pharmacy and Address_________________________________________
Race and Ethnicity Reporting
Please Circle Race: Hispanic White African American Asian American Indian
Other
Prefer not to report
Please Circle Ethnicity: Hispanic or Latino Not Hispanic
Prefer not to report
Please Circle Language: English
Spanish
Indian
Russian
Other
Emergency Contact Information
Relative to Contact in Emergency:______________________Relation:______________ Phone #: ___________
Alternate Emergency Contact:________________________Relation:_______________Phone #: ____________
Primary Insurance Information
Insurance Company Name:_______________________Policy Holder Name:________________________
Policy Holder Date of Birth:_________________________ Relationship to Patient____________________
Secondary Insurance Information
Insurance Company Name:_______________________Policy Holder Name:_______________________
Policy Holder Date of Birth:_________________________ Relationship to Patient__________________
Authorization of Benefits
This medical practice works with its patients to minimize difficulty in the payment of fees for service. Prior to your appointment, you
will be asked to pay those minimal unmet co-insurance amounts which your insurance company authorizes to be collected. Further, we
automatically file insurance claims with your insurance company; therefore, please insure that your primary and secondary insurance
information is current and accurate. By signing below you agree to be responsible for satisfying any unpaid balance left by your
insurance company for the services you receive from our office. I hereby assign all medical and/or surgical benefits, to included major
medical benefits to which I am entitled, including Medicare, private insurance, and other health plans to:
LeBauer Medical Center, PLLC Allergy, Asthma & Sinus Care.
Patient or Responsible Party Signature__________________________
Today's Date:___________

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