Patient Registration Form printable pdf download

Desert Pain Specialists

Date: _____________________

PATIENT REGISTRATION

PLEASE PRINT AND COMPLETE ALL ENTRIES

PATIENT NAME (LAST -- FIRST -- MIDDLE INITIAL)

ADDRESS

CITY, STATE

ZIP

HOME PHONE

WORK PHONE

PATIENT BIRTH DATE

PATIENT SSN

SEX

MARITAL STATUS

 Male

 Female

 Single  Married  Other______________

PATIENT EMPLOYER NAME

PATIENT EMPLOYER ADDRESS (STREET ADDRESS - CITY - STATE - ZIP)

EMPLOYER PHONE

INSURED/RESPONSIBLE PARTY INFORMATION

RELATION TO PATIENT: spouse parent guardian

NAME (FIRST -- LAST -- MIDDLE INITIAL)

ADDRESS (if different from patient)

HOME PHONE

WORK PHONE

SSN

BIRTH DATE

EMPLOYER

INSURANCE INFORMATION

PRIMARY INSURANCE NAME

ADDRESS (STREET - CITY - STATE - ZIP)

PHONE

GROUP NUMBER

ID NUMBER

EMPLOYER

EMPLOYER PHONE

SECONDARY INSURANCE NAME

ADDRESS (STREET - CITY - STATE - ZIP)

PHONE

GROUP NUMBER

ID NUMBER

EMPLOYER

EMPLOYER PHONE

PRIMARY DOCTOR/FAMILY DOCTOR

REFFERING DOCTOR

IN CASE OF EMERGENCY CONTACT

RELATIONSHIP

PHONE NUMBER

ASSIGNMENT AND RELEASE : I hereby authorize my insurance benefits be paid directly to the physician and I am financially

responsible for non-covered services. I also authorize the physician to release any information required in the processing of this

claim and all future claims. If my account is sent to a collection agency, I agree to pay all collection and attorney fees.

SIGNATURE (Patient or, if minor Signature of parent or guardian)

DATE

Authorization to release health information to:

Name(s)

ADDRESS

CITY, STATE

ZIP

HOME PHONE

DAYTIME PHONE

DATES OF SERVICE

AUTHORIZATION EXPIRES (UNLESS OTHERWISE NOTED THIS AUTHORIZATION

WILL REMAIN IN EFFECT ONE YEAR FROM THE DATE SIGNED)



FROM:

TO:

NEVER

DATE:

Release the following information:



All Records

Chart Notes

Radiology Reports

Operative Reports

History & Physicals

RELEASE OF INFORMATION

I understand that:

●

once “this facility” discloses my health information by my request, it cannot guarantee that Recipient will not re-disclose my health information to a

third party. The third party may not be required to abide by this Authorization or applicable federal and state laws governing the use and disclosure of

my health information.

●

I may make a request in writing at any time to inspect and/or obtain a copy of my health information maintained at this facility as provided in the

Federal Privacy Rule 45 CFR (164.524).

●

my records are protected and cannot be disclosed without written permission

●

this Authorization will remain in effect for one year or I provide a written notice of revocation to the Medical Record Department.

SIGNATURE OF PATIENT OR LEGAL REPRESENTATIVE

DATE

IF SIGNED BY LEGAL REPRESENTATIVE, RELATIONSHIP TO PATIENT

SIGNATURE OF WITNESS (Optional):