Hsu Huang Patient Registration Page 3
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1
2
3PATIENT
REGISTRATION
REFERRING
PHYSICIAN:
(PCP)
Last
Name
First
Middle
Address
Apt
#
City
State
Zip
P
Home
Phone
#
Cell
Phone
#
A
T
Date
of
Birth
Age
Sex
SS#
M
S
W
D
Marital
Status
I
E
Employer/School
Spouse's
Name
N
T
OccupaKon
Employer
OccupaKon
City
State
City
State
State
Business
Phone
#
Business
Phone
#
Drivers
License
#
Date
of
Birth
SS#
Nearest
Friend/Rela4ve
NOT
Living
With
You
Rela4onship
Phone#
Primary
Insurance
Secondary
Insurance
Name
of
Insurance
Company
Name
of
Insurance
Company
I
Insured
Name
Date
of
Birth
Insured
Name
Date
of
Birth
N
S
Subscriber
ID/Member
Number
Subscriber
ID/Member
Number
U
R
Group
Number
Group
Number
E
D
Phone
Number
to
Verify
Coverage
Phone
Number
to
Verify
Coverage
Fill
out
the
Parents
Sec4on
below
ONLY
if
the
Pa4ent
is
a
Minor:
(Father
&
Mother)
Father
Mother
Last
Name
First
Middle
Last
Name
First
Middle
P
Address
Apt
#
Address
Apt
#
A
R
City
State
Zip
City
State
Zip
E
N
Home
Phone
#
Date
of
Birth
Home
Phone
#
Date
of
Birth
T
S
Employer
OccupaKon
Employer
OccupaKon
SS#
Drivers
License
#
SS#
Drivers
License
#
I
understand
that
if
any
of
the
insurance
I
have
provided
is
incorrect
or
if
I
fail
to
no4fy
the
office
of
any
insurance
changes,
and
/
or
addi4onal
coverage,
that
I
am
responsible
for
all
physician
charges.
I
hereby
authorize
the
release
of
any
medical
informa4on
necessary
for
the
processing
of
insurance.
I,
hereby
assign
all
medical
and
/
or
surgical
benefits
to
which
I
am
en4tled
to
C.
E.
Huang,
M.D.
This
assignment
will
remain
in
effect
un4l
revoked
by
me
in
wri4ng.
A
photocopy
of
this
assignment
is
to
be
considered
as
valid
as
an
original.
Pa4ent
(or
Legal
Guardian)
Signature
___________________________________
Today's
Date
_________________
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