Dr.FaithHackett Dr. Jacalyn Ginsburg Dr. Jeffrey Schmidlein Dr. Kim Bondurant
“SPDOCS” Patient REGISTRATION FORM
Today’s date: / Physician:PATIENT INFORMATION
Patient’s First , Middle, Last Name / Jr. NicknameSr.
___ / Maiden Name
(If applies)
Marital Status / Sex M/F / Social Security # / Birth Date
Street address / City State / Zip
Best phone #s to reach you:
specify if home or cell, if cell who / #1 / #2 #3
it belongs to.
EmailAddress / Race: Circle please
White/African Am/Asian/Native Am/Alaskan/Other/Refuse / Ethnicity: Circle please
Non-Hispanic/Hispanic/Refuse
Pharmacy Name/Address/Phone#/Fax / Name of Parents(Pediatric Patients Only)
In case of emergency, who can we notify? / Name: / Home and Cell#
Primary Health INSURANCE INFORMATION
Please give your insurance card to the receptionistName of Health Insurance / PCP Co-pay
$ / Subscriber’s name: / Subscriber’s DOB:
Subscriber SSN / Policy# Group# Patient’s relationship to subscriber:
Self Spouse Child Other
Effective Date:
SECONDARY INSURANCE: / MAIL AWAY RX PLAN NAME
Name of secondary insurance (Medicare pts only) / Subscriber’s name: / Subsc. DOB / Subscr. SSN
Patient’s relationship to subscriber: / Self
Spouse / Child
Other / Policy#
Group# / Mail Away RX Plan
Responsible Party
Person responsible for any balance: / Relationship to patient: / Home # / Cell #CONSENT, ASSIGNMENT AND RELEASE: / *Please read carefully
The above information is true to the best of my knowledge.
Assign of Benefits and Info Release: I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize SPDOCS or insurance company to make referrals on my behalf and share relevant clinical or demographic information required to process my claims as outlined in the Notice of Privacy Practices.
Consent for Treatment: I understand that medical treatment and examinations is/or may become necessary for the patient by your physician. I hereby consent to and authorize the administration of all diagnostic tests and treatments that may be considered advisable or necessary in the judgment of the physician.
Test Results: I understand that I am responsible to contact the office to obtain any and all test results.
Privacy Practices: I consent to the use of my medical information as outlined in section 1A of the Notice of Privacy Practices.
Fees: I understand that I am responsible for deductibles, co-pays, non-covered services, late cancellation fees as posted and any collection agency charges.
Medications Release: I consent to have the pharmacy release my prescription medication history to my physician via the Surescripts clearinghouse and to the submission of electronic prescriptions to my preferred pharmacy.
Patient/Guardian signature / Date