Instructions:For this assignment, use the attached patient registration form and complete the form in its entirety.It can be made-up information on the form.Use critical thinking skills as you will also need to research and provide a brief description of any additional information that would need to be included/collected from the new patient along with their registration form. Provide this information in a separate document.
Insurance cards copied ?
Date: _______________
Patient Registration
Information
Please PRINT AND complete ALL sections below!
Is your condition a result of a work injury? YES
NO
An auto accident? YES
NO
Account # : ___________________
Insurance # : __________________
Co-Payment: $ ________________
Date of injury: ______________
PATIENT’S PERSONAL INFORMATION
Marital Status: ? Single ? Married ? Divorced ?Widowed Sex: ? Male ? Female
Name: : ______________________________________________ ________________________________________________ _________
Last name
First Name
initial
Street Address: ______________________________________(Apt #____) City: ___________________ State: _______ Zip: __________
Home phone: (_____) __________________________Work phone: (____)_______________ Social Security # _______ – _____ – _______
Date of Birth: _______/_______/________ Driver’s License: (State & Number) ________________________________________________
Month
day
year
Employer / Name of School _______________________________________________________________ ? Full Time ? Part Time
Spouse’s Name: ___________________ ______________________ __________ Spouse’s Work phone: (_____) ___________________
Last name
First name
Initial
How do you wish to be addressed? ___________________________________________ Social Security # ________ – _______- ________
PATIENT’S / RESPONSIBLE PARTY INFORMATION
Responsible party: ______________________________________________________________ Date of Birth : ______________________
Relationship to Patient: ? Self ? Spouse ? Other _____________________________ Social Security # _________ – ______ – ________
Responsible party’s home phone: ( _____ ) ________________________________ Work phone : ( _____ ) _________________________
Address: _______________________________________(Apt # ______ ) City: ___________________ State: ______ Zip: __________
Employer’s name: _________________________________________________ Phone number: ( ____ ) ____________________________
Address: ___________________________________________________ City: ___________________ State: ______ Zip: __________
Your occupation: ___________________________________________________
Spouse’s Employer name: _______________________________________________ Spouse’s Work Phone: ( _____) _________________
Address: ____________________________________________________ City: __________________ State: ________ Zip: _________
PATIENT’S INSURANCE INFORMATION
Please present insurance cards to receptionist.
PRIMARY insurance company’s name: ________________________________________________________________________________
Insurance address: _______________________________________________ City: __________________ State: ________ Zip: _________
Name of insured: ______________________________________________ Date of Birth: _____________Relationship to insured:
Insurance ID number: _______________________________________________________ Group number: __________________________
SECONDARY insurance company’s name: _____________________________________________________________________________
Insurance address: _______________________________________________ City: __________________ State: ________ Zip: _________
Name of insured: ______________________________________________ Date of Birth: _____________Relationship to insured:
Insurance ID number: _______________________________________________________ Group number: __________________________
Check if appropriate: ? Medigap policy ? Retiree coverage
PATEIENT’S REFERRAL INFORMATION
Referred by: ______________________________________________________ If referred by a friend, may we thank her or him? YES NO
Name(s) of other physician(s) who care for you: ________________________________________________________________________
________________________________________________________________________
EMERGENCY CONTACT
Name of person not living with you: ____________________________________________________ Relationship: ___________________
Address: ___________________________________________ City: ______________________ State: __________ Zip: ______________
Phone number (home): (______) _______________________ Phone number (work): (______) ____________________________________
Assignment of Benefits ? Financial Agreement
I hereby give lifetime authorization for payment of insurance benefits to be made directly to __________________________, and any assisting
physicians, for services rendered. I understand that I am financially responsible for all charges whether on not they are covered by insurance.
In the event of default, I agree to pay all costs of collection, and reasonable attorney’s fees. I hereby authorize this healthcare provider to
release all information necessary to secure the payment of benefits.
I further agree that a photocopy of this agreement shall be as valid as the original.
Date: ________________________ Your signature: ________________________________________________________________________
Method of payment: ? Cash ? Check ? Credit Card
PATIENT REGISTRATION

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