*Please complete the patient registration to turn in for your first visit.
PATIENT REGISTRATION
Patient's full name: ________________________________ Today's date: ________
Home address: ________________________ City: ____________ State: _________
Zip: ________ Home #:______________ Age: ____ DOB: ________
Patient employer: _______________________ Phone #: ________________
If student, HS or College: __________________
Family Physician: _________________
INSURED/RESPONSIBLE PARTY INFORMATION
Full name of insured: _________________________ Relationship: _______________
Occupation: __________________ Home address: _________________________
Phone #: ________________
Employer and address: ___________________________ Phone #: _________________
Full name of spouse: ____________________ Spouse employer: __________________
Insured's primary insurance company: ____________________ I.D.#: _______________
Group #: ______________
OFFICE BILLING AND INSURANCE POLICY
1. I authorize use of this form on all of my insurance submissions.
2. I authorize the release of information to my insurance company.
3. I understand that I am responsible for the full amount of my bill for services provided.
4. I authorize direct payment to my service provider.
5. I hereby permit a copy of this to be used in place of an original
Name: __________________________
Signature: __________________________ Date: ___________
It is your responsibility to pay any deductible amount, co-pay, co-insurance, amount or any other balance not paid by your insurance the day and time service provided.
There will be a $50 service charge on all returned checks.
In event that your account goes to collection, there will be a 20% collection fee added to your balance.
There is a 24 hr cancelation policy which requires you cancel your appt. 24 hours in advance to avoid being charged $50.
Signature: __________________________ Date: ____________
