Patient Registration Form 1 - Free Download
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Patient Registration Form 1
Patient Registration Form 1
Pioneer Comprehensive Medical Date: _____________________
PATIENT REGISTRATION
PLEASE PRINT AND COMPLETE ALL ENTRIES
PATIENT NAME (LAST -- FIRST -- MIDDLE INITIAL) ADDRESS
CITY, STATE ZIP HOME PHONE CELL PHONE
PATIENT DATE OF BIRTH PATIENT SSN SEX
Male Female
MARITAL STATUS
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
FROM: TO:
AUTHORIZATION EXPIRES (UNLESS OTHERWISE NOTED THIS AUTHORIZATION WILL
REMAIN IN EFFECT ONE YEAR FROM THE DATE SIGNED)
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 EMAIL
IF SIGNED BY LEGAL REPRESENTATIVE, RELATIONSHIP TO PATIENT SIGNATURE OF WITNESS (Optional):
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