Sample Patient Registration Form
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1Today’s Date:
___________
PATIENT REGISTRATION FORM
Patient Information
Name ________________________________________________________
Sex
Male
Female
Last
First
Middle
Address _______________________________________________________
Mr
Mrs
Miss
Ms
Street
Apt #
_______________________________________________________
Marital Status
City
State
Zip
Single
Married
Divorced
Email
_______________________________________________________
Widowed
Separated
Home Phone _______________________________
Cell Phone ____________________________
Social Security # ____________________________
Birthdate _____________________________
Employment Status
Full
Part
Retired
Not Employed
Student Status
Full Time
Part Time
Employer _________________________________________
Work Phone ___________________________
Emergency Contact ___________________________________________
Phone ________________________________
If a Minor, Parent/Guardian Name ________________________________
Phone ________________________________
Guarantor/Responsible Person Information
Name ________________________________________________________
Last
First
Middle
Mr
Mrs
Miss
Ms
Address _______________________________________________________
Relationship to Patient ________________
Street
Apt #
_______________________________________________________
City
State
Zip
Home Phone _______________________________
Cell Phone ____________________________
Insurance Information (please allow us to copy your card(s))
Primary
Secondary
Ins Company Name_________________________________
Ins Company Name_________________________________
Policy Holder Information
Policy Holder Information
Name ____________________________________________
Name ___________________________________________
SS# __________________________________
SS# __________________________
Birthdate _____________________________
Birthdate _____________________
Relationship to Patient _____________________________
Relationship to Patient _____________________
ASSIGNMENT OF BENEFITS: I hereby assign all medical/surgical benefits to which I am entitled including major medical, Medicare, private
insurance or other health plan benefits to the Zubritzky and Christy OB-Gyn, division of St Clair Medical Services. This assignment will
remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I hereby
authorize said assignee to release all information necessary to secure payment.
MEDICARE: I request that Medicare benefits be made on my behalf to Zubritzky and Christy OB-Gyn, division of St Clair Medical Services for
healthcare services furnished. I authorize any holder of medical information about me to release to HCFA and its agent any information
needed to determine these benefits or the benefits payable for related services; I understand that my signature authorizes the release of
medical information needed to pay the claim. If “other health insurance” is indicated in item 9 of the HCFA-1500 form or elsewhere on
other approved claim forms or electronically submitted claims, my signature authorizes release of the information to the insurer or agency
shown. In Medicare assigned cases, the physicians agree to accept the charge determination of the Medicare carrier as the full charge and
the patient is responsible only for the deductible, coinsurance and any non covered services. Co-insurance and deductible amounts are
based upon the charge determination of the Medicare carrier.
________________________________________________________
__________________________________
Signature of Patient or if a minor, Responsible Party
Date
Rev 1/11
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Parent category: Medical