Patient Registration Form Account - Baton Rouge Cardiology Center Page 2

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(Emergency Contact Information) Name of Person to Contact
Phone
Relationship to You
Do you have medical insurance?
Yes
No
Primary Insurance
Secondary Insurance
How did you learn about our practice? (Please check only one referral source.)
(To)
My doctor referred me. Doctor’s first and last name who referred you
Family/Friends (1732)
Print Ad (5078)
St. Elizabeth Emergency Room (2033)
Health Fair (2598)
Newspaper (2568)
Our Lady of the Lake Emergency Room (1735)
Yellow Pages (1731)
TV (2596)
Baton Rouge General Mid City Emergency Room (1736)
Internet/Website (2569)
Radio (2597)
Baton Rouge Health Center Emergency Room (1739)
Email (2305)
Flyer/Brochure (2599)
Lane Regional Medical Center Emergency Room (1738)
Facebook (5076)
Insurance (2570)
St. James Parish Hospital Emergency Room (3822)
Other
Do you have a Primary Care Physician or Family Doctor?
Yes
No
(From)
Primary Care Physician Name
Phone
(First and last name, please.)
Physician Address
City, State, Zip
Assignment Authorization / Medical Records Release Authorization:
I hereby authorize Baton Rouge Cardiology Center to release to your insurance company representative, any information including the diagnosis and
the records of any treatment or examination rendered to me during the period of such Medical or Surgical care. I authorize and request your
insurance company to pay directly to the doctor the amount due to me in my pending claim for Medical or Surgical treatment or services, by reason
of such treatment or services rendered to me. A photographic copy of this authorization shall be as valid as the original. I understand I am financially
responsible for payment on this account at all times.
Signature of Insured
Date

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