Women’s Health Center

Dr. David P. Gorman

REGISTRATION FORM

               

Office Use Only                                                                                                            Account

                                                                                                                                  Number   l___l___l___l___l___l___l___l___l

                                                                                                                                  Ins. Code  1  ______

                                                                                                                                  Ins. Code  2  ______

Please Print

Today’s date:

Primary Care Physician:

PATIENT INFORMATION

Patient’s last name:

First:

Middle:

q Mr.

q Mrs.

q Miss

q Ms.

Marital status (circle one)

 

Single  /  Mar  /  Div  /  Sep  /  Wid

Is this your legal name?

If not, what is your legal name?

(Former name):

Birth date:

Age:

Sex:

q Yes

q No

 

 

       /          /

 

q M

q F

Street address:

Social Security no.:

Home phone no.:

 

 

(          )

P.O. box:

City:

State:

ZIP Code:

 

 

 

 

Occupation:

Employer:

Employer phone no.:

 

 

(          )

Chose clinic because/Referred to clinic by (please check one box):

q Dr.

 

q Insurance Plan

q Hospital

q Family

q Friend

q Close to home/work

q Yellow Pages

q Other

 

Other family members seen here:

 

INSURANCE INFORMATION

(Please give your insurance card to the receptionist.)

Person responsible for bill:

Birth date:

Address (if different):

Home phone no.:

 

       /         /

 

(          )

Is this person a patient here?

q Yes

q No

 

 

Occupation:

Employer:

Employer address:

Employer phone no.:

 

 

 

(          )

Is this patient covered by insurance?

q Yes

q No

 

Please indicate primary insurance

q Medicare

q Medicaid

q Blue Cross

q Other

 

Subscriber’s name:

Subscriber’s S.S. no.:

Birth date:

Group no.:

Policy no.:

Co-payment:

 

 

       /       /

 

 

$
Patient’s relationship to subscriber:

q Self

q Spouse

q Child

q Other

 

Name of secondary insurance (if applicable):

Subscriber’s name:

Group no.:

Policy no.:

 

 

 

 

Patient’s relationship to subscriber:

q Self

q Spouse

q Child

q Other

 

IN CASE OF EMERGENCY

Name of local friend or relative (not living at same address):

Relationship to patient:

Home phone no.:

Work phone no.:

 

 

(          )

(          )

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Women’s Health Center or insurance company to release any information required to process my claims.

 

Patient/Guardian signature

 

Date

 

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