Patient Registration Form

Personal Information:

Patient Name: _______ ~ Preferred Name: ________________________________

Last First Middle

DOB: _____ / ______ / ______ Age: _____ Male: □ Female: □ SSN: ______ - ______ - ______ DL Number:_________________

Marital Status: Single □ Married □ Widowed □ Divorced □ Other □ _______________

Address: _________________ Apt: ______________ Primary Phone: ( ) ________ -- _________

City: State: Zip: Secondary Phone: ( ) ________ -- _______

Emergency Contact: Name: ___ Relationship: ____ Phone: ( ) _______ - _______

How did you hear about Inglewood Family Health: Referral □ Family / Friend □ Other □ _________________________________

Employment Information:

Patient’s Employer: _______ Occupation: ______________

Employer’s Address: Suite: Employer Phone: ( ) ________ - _________

City: State: Zip: Employer Fax: ( ) _________ - __________

Insurance Information: ~ Please hand your insurance cards to receptionist.

Do you have medical assistance from the state (DSHS) ~ Yes □ No □

Primary Insurance Company: _ ___ Secondary Insurance Company: ______

ID / Member #: ___ Group#: ___ ID / Member #: ___ Group #: __________________

Subscriber Name: ___ Subscriber Name: ____________________

Subscriber’s DOB: _____ / ______ / ______ Subscriber’s DOB: ______ / ______ / ______

Subscriber’s Employer: __ Subscriber’s Employer: ___

Relationship to Subscriber: _________ Relationship to Subscriber: __________________

Financially Responsible for Bill:

Name:____________________________________________________________ Relationship: _______________________________

Address: Apt: Primary Phone: ( ) _________ - ___________

City: _ State: Zip: Secondary Phone: ( ) _________ - __________

Please Initial / Sign / Date:

I ___________________________, understand and agree that:

-- Health & Accident Insurance policies are an arrangement between the insurance plan and myself.

-- Inglewood Family Health will submit claims to my insurance as a contracted provider.

______ -- All services provided to me by Inglewood Family Health are my personal financial responsibility.

-- If care is suspended or terminated, I still will be responsible for my outstanding account balance.

______ I hereby authorize my insurance benefits be paid directly to my provider. My provider and /or insurance company has my

permission to release information required for payment of my claims.

Signature: Date: _______ / _______ / ________

Patient or Parent / Guardian