Allergy & Asthma Treatment Center, Inc. Patient Registration
Patient Name______[ ]Male [ ]Female Birth date: ______Age______
Address:______City ______State:______Zip______
Alternate address for mailing (optional): ______
Home Phone: ______Work Phone: ______Cell Phone: ______
Social Security # ______Employer/School: ______Occupation: ______
Marital status: [ ] Single [ ]Married [ ] Divorced [ ]Widowed. For minors only: child lives [ ] with both parents [ ]Mother [ ] Father
May we leave a message at your home with other residents? [ ]Yes [ ]No. On your answering machine/voice mail? [ ]Yes [ ]No
Who may we talk to about your medical concerns? ______Relationship to this person: ______
Emergency Contact: ______Is this contact for emergency purposes only? [ ]Yes [ ] No, they can be
contacted regularly about my care. Relationship to this person: ______Phone: ______
Referring Physician: ______Address: ______Phone Number: ______
Mother/Guardian: ______Address (if different) ______e-mail______
Date of Birth: ______Home Phone: ______Work Phone: ______Cell Phone: ______
Father/Guardian: ______Address (if different) ______e-mail______
Date of Birth: ______Home Phone: ______Work Phone: ______Cell Phone: ______
Primary Insurance Company: ______Name of Policy Holder______
ID Number______Group Number______
Insured’s Date of Birth______Social Security # ______Employer______
Relationship to card holder: [ ] Self [ ] Spouse [ ] Co-payment; $______Effective Date______
Secondary Insurance Company______Effective Date______Name of Policy Holder: ______
Insured’s Date of Birth______ID Number: ______Group Number______
Card holder: [ ]Self [ ] Spouse [ ]other ______Employer______
Responsible Party Information: Responsible part is: [ ] Patient [ ]Primary Policy Holder
Please complete the information below if the person responsible for the bill is not the patient or policy holder.
Name: ______Address: ______
Home Phone:______Work Phone: ______Social Security #______
Relationship to patient: [ ] Spouse [ ] Parent [ ]Guardian [ ]Other Obtain copy of Driver’s license [ ] Yes [ ] No
I agree to the assignments and financial responsibilities shown on the back of this form. You should read those terms carefully.
X ______Date______e-mail ______
How did you hear about us? ______
ASSIGNMENTS AND FINANCIAL RESPONSIBILITIES
Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid for by your insurance.
IN ORDER TO CONTROL YOUR COST OF BILLINGS, WE REQUEST THAT YOUR CO-PAY FOR OFFICE VISITS BE PAID AT THE CONCLUSION OF EACH VISIT.
If this account is assigned to an attorney for collection and/or suit, the practice shall be entitled to reasonable attorney’s fees and cost of collection. You will be held responsible for any fees and costs encountered under these conditions.
I authorize the release of any information necessary to determine liability for payment and to obtain reimbursement on any claim.
I request that payment of authorized benefits be made on my behalf. I assign the benefits payable to which I am entitled including Medicare, private insurance and other health plans to the practice named on the other side of this form.
This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance.