New Patient Registration Form

ST. LUKE’S - ROOSEVELT HOSPITAL CENTER – 258A

NEW PATIENT REGISTRATION FORM

DATE

APPOINTMENT WITH

MR#

PATIENT INFORMATION

PATIENT’S LAST NAME/Apelido Del Paciente

FIRST NAME/Primer Nombre

DOB

AGE/Edad

SOCIAL SECURITY #

STREET ADDRESS/DIRECCION

APT.#

City/Ciuad

State

Zip Code

Country

SEXISexo (CIRCLE ONE)

M

F

HOME PHONE NO./Telephono

WORK PHONE NO.

MARITAL STATUS

SPOUSES NAME

SPOUSE’S WORK No.

EXT.

(

)

(

)

S

M W D SP

PATIENT EMPLOYER/Patron Del Pacienté

F/T STUDENT

ALLERGIES

Y

N

EMPLOYER’S ADDRESS/Direccion Del Patron

City/Ciuad

STATE/Estado

ZIP CODE

EMERGENCY CONTACT/Contacto De Emergencia

RELATIONSHIP TO PATIENT

CONTACT’S HOME PHONE NO.

CONTACT’S WORK PHONE

EXT.

(

)

(

)

REFERRING MD NAME

ADDRESS

CITY

STATE

ZIP CODE

PHONE NO.

(

)

PRIMARY DOCTOR

ADDRESS

CITY

STATE

ZIP CODE

PHONE NO.

(

)

GUARANTOR INFORMATION – Person responsible for payment, if other than self

GUARANTOR’S LAST NAME

FIRST NAME

RELATIONSHIP TO PATIENT

SOCIAL SECURITY

DOB

HOME PHONE NO.

(

)

GUARANTOR’S ADDRESS

APT #

CITY

STATE

ZIP CODE

COUNTRY

SEXISexo (CIRCLE ONE)

M

F

GUARANTOR’S EMPLOYER

ADDRESS

CITY

STATE

ZIP CODE

WORK PHONE

EXT.

(

)

INSURANCE INFORMATION

MEDICARE

EFF. DATE

MEDICAID #

EFF. DATE

PRIMARY INSURANCE COMPANY

EFF. DATE

POLICY #

GROUP #

CERTIFICATE #

ADDRESS

CITY

STATE

ZIP CODE

PHONE NO.

(

)

NAME OF INSURED

PATIENT RELATIONSHIP TO INSURED

SOCIAL SECURITY #

DOB

SEXISexo (CIRCLE ONE)

M

F

INSURED’S ADDRESS

APT.

CITY

STATE

ZIP CODE

COUNTRY

HOME PHONE NO.

(

)

INSURED’S EMPLOYER

WORK PHONE NO.

(

)

SECONDARY INSURANCE COMPANY

EFF. DATE

POLICY #

GROUP #

CERTIFICATE #

ADDRESS

CITY

ZIP CODE

STATE

PHONE NO.

(

)

NAME OF INSURED

PATIENT RELATIONSHIP TO INSURED

SOCIAL SECURITY

DOB

SEXISexo (CIRCLE ONE)

M

F

INSURED’S ADDRESS

APT.

CITY

STATE

ZIP CODE

COUNTRY

HOME PHONE NO.

(

)

INSURED’S EMPLOYER

WORK PHONE NO.

(

)

AUTHORIZATION INFORMATION

ASSIGNMENT OF BENEFITS:

I hereby assign to ______________________________________________ any insurance, or other third-party benefits available for health care

................................................... NAME OF PRACTICE ................................................................................................................................................

services provided to me. I also understand that if benefits are assigned, or if by contractual arrangement, payment to the practice will be made by

my insurance, that I am responsible for any co-payments and deductibles and that these amounts are due at the time services are rendered. I

understand that the above practice has the right to refuse or accept assignment of such benefits (except when prohibited by contract). I also

understand that in the event that services rendered are not covered under my "insurance", I will accept financial responsibility for all services

provided to me. If benefits are not assigned to this practice, I agree to forward to the practice, all "insurance" payments that I receive for services

rendered to me immediately upon receipt and/or to make payment, in full, for the services rendered to me (depending upon the agreement) at this

time.

Signature of Patient/Legal Guardian: _____________________________________________________ Date: ________________________

FOR RELEASE OF INFORMATION:

I authorize the release of any medical or other information as is necessary to process this claim based upon the "HIP AA Notice of Privacy

Practices" information provided to me under separate cover. This information is on file as a permanent record and may be amended as is

necessary.

Signature of Patient/Legal Guardian: _____________________________________________________ Date: ________________________