Buffalo Medical Group Patient Registration Form

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* Please complete this form and bring it with you to your appointment *
BUFFALO MEDICAL GROUP
PATIENT REGISTRATION FORM
PATIENT DEMOGRAPHICS
Patient Last Name; First; M.I.__________________________________________________________________
SS# _____-_____-_____ (optional)
Birth Date _____ /_____ /_____
Sex: (Circle One) M or F
Address: __________________________________________________________________________________
City: _______________________________
State: ____________
Zip: ____________
Home Phone (
) ______ - __________ Work Phone (
) ______ - _________ Cell Phone (
)____-______
REFERRING PHYSICIAN
Referring Physician: _______________________________________________ Phone #: ________________
Primary Care Physician: ____________________________________________ Phone #: ________________
EMPLOYER
Employer Name: ____________________________________________ Phone #: _____________________
Employer Address:__________________________________________ Occupation:____________________
**If Spouse insurance is primary over Medicare, please complete the following:
Name of Spouse Employer: ____________________________________ Spouse DOB: ____/_____/_______
Spouse Employer Address:____________________________________________________
EMERGENCY CONTACT
Emergency Contact: ________________________________________________________________________
Relationship to Patient: _____________________
Phone #: ____________________________
Address: _________________________________________________________________________________
City: __________________________________
State: __________ Zip: ____________________
INSURANCE
Primary Ins: ___________________________________________
ID. #: _______________________
Policy Holder: _________________________________________
Group #: _____________________
Relationship to Patient: ________________________
Secondary Ins: ___________________________________________
ID. # ________________________
Policy Holder: ____________________________________________ Group #: ________________________
Relationship to Patient: __________________
Is this a Worker’s Compensation Case? Yes.____ No ____
No Fault? Yes ____ No____
Case # or Policy # ______________________________________ Date of Accident: _____/_____/______
Insurance Carrier: __________________________________________________________________________
Insurance Carrier Address:___________________________________________________________________
Direct Payment Request and Authorization to Release Medical Information
“I hereby authorize the release of information acquired during the course of my examination and treatment to the CMS and its’ agents, or any other
third party carrier as necessary to secure payment of any benefits due to me, I hereby assign payment of said benefits to include Medicare benefits
directly to my physician. I understand that I am responsible for all charges regardless of insurance status, as well as any associated costs for
collection should such action become necessary, I agree that this authorization shall, be valid until canceled in writing or replaced by one of a later
date. A photocopy of this assignment shall, be considered as valid as the original. I have read the above and fully understand the terms thereof.”
_____________________________________________________________________________________________________________________
Patient Signature
Date
BMG.40 (1/06)

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