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Patient Registration Form 2

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Patient Registration Form 2
Patient Registration Form 2
College Park Family Care Center
Compassionate, quality care.
PATIENT
GUARANTOR
(
person who signed Financial Responsibility, must be
at least 18yrs old, if different from pt
)
Pt Relationship Child Spouse Other
Last Name
First Name, Middle
Address, Apt #
City, State, Zip
Today’sDate:__________________________
PrimaryDoctor:________________________
SSN
Date of Birth
Gender
Male Female Male Female
Marital Status
Single Married Divorced Widow(ed) Other
Race (choose one)
Amer Indian/AK Native Asian Black/Afri-American
Native HI-Othr Pacific Isl White/Cauc Other/Declined
Ethnicity (choose one)
Hispanic or Latin Not Hispanic or Latin Declined
Preferred Language
English Spanish Other; Specify:
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PATIENT REGISTRATION
FORM
Home Phone
Mobile Phone
Email Address
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Employer / School
Work Address
Work Phone
EMERGENCY CONTACT #1 EMERGENCY CONTACT #2
Name
Home Phone
Employer / Mobile Phone
Relationship
Complete if Card Present
Effective Date (mm/dd/yy): Effective Date (mm/dd/yy):
Insurance Company Name
Policy Owner Name
Policy Owner Date of Birth
Relationship to Patient
PRIMARY INSURANCE SECONDARY INSURANCE
Complete if Card not Present
Effective Date (mm/dd/yy): Effective Date (mm/dd/yy):
Insurance Company Name
Policy / ID #
Group / Employer #
Claims Mailing Address
Relationship to Patient
Policy Owner Name
Policy Owner Date of Birth
City, State, Zip
Copay: (Prim - Spec - U/C)
Insurance Type
HMO PPO Other; Specify: HMO PPO Other; Specify:
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Patient Registration Form 2