Patient Registration Form (Page 2 of 2) in pdf

Patient Registration Form Page 2

Arturo Bravo, M.D., P.A.

11307 FM 1960 West, Suite 370

Houston, TX 77065

Patient Registration Form, Continued

How were you referred to our practice?  Friend/Relative, if so, name:

 Yellow Pages

 Physician, if so, name:

 Receiving Mail

 Newspaper

 Hospital referral

 Other?

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the physician, but is

usually not designed to pay the entire fee. Because insurance companies vary in the amount they will pay for various

services, it is ultimately your responsibility to pay the portion of the bill not paid by your insurance company (unless

otherwise restricted by law or an agreement we might have made with insurer).

I authorize any holder of medical or other information about me to release to the Social Security Administration and

Centers for Medicare and Medicaid Services or its intermediaries or carrier or any other commercial insurance company,

any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the

original, and request payment of medical insurance benefits either to myself or to the party who accepts assignment.

I have received notice of this organization’s privacy policies.

Signature:

Date:

Patient Registration Form Page 2