Patient REGISTRATION FORM

2

(Please Print Clearly)
Today’s date:
DD/MM/YYYY / Dr. Mandry

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? q Yes q No
(For insurance purposes, please provide name as it is on social security card.) / Birth date:
/ Age: / Sex:
DD/MM/YYYY / q M / q F
Street address: / Cell Phone Number: / Home phone no.:
( ) / ( )
P.O. box: / City: / State: / ZIP Code:
Personal Email: / Employer: / Employer phone no.:
( )
Employers’ address:
Social Security no: / If Dependent, Guardian name:
Relationship:

INSURANCE INFORMATION

(Please fill as best as you can and give your insurance card to the receptionist.)
Policy holders’ name: / Birth date: / Address of policy holder (if different): / Policy holder phone no.:
DD/MM/YYYY / ( )
Relationship: q SPOUSE q PARENT q OTHER q GUARDIAN q SELF
Occupation: / Employer: / Employer address: / Employer phone no.:
( )
Is this patient covered by insurance? / q Yes / q No
Please indicate primary insurance:
q Cigna qAvmed qAnthem BC/BS q United qAETNA q Wellcare q Humana q Multiplan
q Medicare q Careplus qSimply health q First Health qOptimum qFreedom q Other ______
Subscriber’s name: / Subscriber’s S.S. no.: / Birth date: / Group no.: / Policy no.: / Co-payment:
DD/MM/YYYY / $
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: / Relationship to patient: / Home phone no.: / Work phone no.:
( ) / ( )
Address: / Cell Phone No.:
( )
LIFETIME AUTHORIZATION: I understand that my insurance is a contract between my insurance company and myself. I am responsible for payment of services at the time it is rendered at Endocrine Associates of Florida, P.A. I authorize my insurance benefits be paid directly to the physician, Dr. José M Mandry, or other physician that may have joined in the practice that rendered care on my behalf. I also authorize Endocrine Associates of Florida to release any information required to process my claims. I permit a copy of the authorization to be used in place of the original and request payment of medical insurance benefits to the party that accepts assignments. Furthermore, I authorize treatments of my condition. I confirm that the above information is true to the best of my knowledge.
Preferred method of payment:  Cash  Credit (Sorry that we cannot accept checks or keep credit info on file)
Patient/Guardian signature / Date