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Patient Registration Form 1

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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 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)
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):
Patient Registration Form 1
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