Patient Registration
Last Name:                                              First name:                                       Middle(initial):_______

Date of Birth:                             Age:                             Social Security:                                            

Address:                                                                                              Apt #:                                    

City:                                           State:                                      Zip Code:                                         

Home Phone:                              Cell Phone:_________________Email:_______________________

Insurance Information

Primary Insurance Name:                                                                                                                 

Subscribers Name:                                    Subscribers S.S. #:                            Birth date:                       

Policy Number:                                      Group Number:                               Co-payment:                       

Secondary Insurance Name:                                                                                                             

Subscribers Name:                                    Subscribers S.S. #:                            Birth date:                       

Policy Number:                                                                                        Group Number:                       

In Case of an Emergency

Name:                                     Relationship to Pt:                                       Phone number:                                 

 

I authorize my insurance benefits be paid to the physician. I understand that I am financially responsible for any additional balance. I Also Authorize (Name of Practice) or insurance company to release any information required to process my claim.

 

Patient Signature:___________________________________                            Date:___________________________

Release of Medical Consent
HIPAA AUTHORIZATION FORM TO RELEASE HEALTHCARE INFORMATION

 

Last Name:                                               First name:                                       Middle(initial):               

Date of Birth:                                     Social Security:                                         Phone:                                   

By signing this form, I authorize you to release confidential health information about me, by releasing a copy of my past medical records to the physician/ Facility/entity listed below

The information you may release: Please circle

  1. Complete Records
  2. Lab Reports
  3. Medication record
  4. Radiology reports
  5. Other (Please Specify):                                                                                                                                                             

 

Release my following protected health information to the following: Physician/Person/Facility/ Entity

Name:                                                                                                                                                

Address:                                                                                                                                             

City/State/ Zip:                                                                                                                                   

Phone:                                                                         Fax:                                                               

 

Patient Signature:                                                                                             Date:                                                           

 

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