PATIENT REGISTRATION FORM updated 4/8/15
Welcome to Family Medical Associatesof Raleigh!
Please complete this entire form, or notify our staff if you are unable to.
PATIENT INFORMATION
Last Name: ______First: ______M.I.______
D.O.B. ____/____/______SS# ______Gender: ______Race: ______
Primary Language: ______Ethnicity: ______Marital Status:______
Mailing Address: ______Apt.#______
City:______State:______Zip:______DL State/#: ______
Home Phone ______Work Phone______Ext______
Cell Phone______Email______
Preferred Method of Communication: Email Text Phone Call Mail
If your Physical Address is different than your mailing address, please state: ______Apt. #______City: ______State: ______Zip: ______
Pharmacy Name and Location: ______
Pharmacy Phone #: ______
Spouse’s Name: ______Spouse’sPhone #: ______
Emergency Contact Person: ______Emergency Phone #: ______
Employer Name: ______Employer Phone #: ______
Employer Address: ______
Do you have health insurance? ______Yes______No
RESPONSIBLE PARTY IF NOT SELF (PARENT OR GUARDIAN)
Last Name: ______First: ______M.I. ______
D.O.B. ____/____/______SS# ______DLState/# ______
Gender: ______Race ______
Mailing Address: ______Apt.#______
City:______State:______Zip:______
INSURANCE INFORMATION (PLEASE PRESENT YOUR INSURANCE CARD WITH THIS FORM)
Primary Ins. ______Policy Holder ______D.O.B.____/____/____
Relationship: ______Policy # ______Group# ______
SS#______Employer: ______
Secondary Ins. ______Policy Holder______D.O.B. ___/___/_____
Relationship: ______Policy # ______Group# ______
SS#______Employer: ______
Patient Acknowledgment and Consent updated 1/21/15
Patient Name:______DOB:______
CONSENT FOR TREATMENT:I consent to treatment, examinations, procedures and diagnostic testing providedby Family Medical Associates of Raleigh, which are deemed necessary.
HIPAA:I have been provided access to a copy of the Notice of Privacy Practices.. I understand that my medical information may be required for payment of insurance benefits or by specialists that I have been referred to for my ongoing care.
COMMUNICATION: I authorize Family Medical Associates of Raleigh to leave messages regarding my medical treatment at the numbers previously givenexcept for: ______.
I will notify Family Medical Associates of Raleigh if I would like to share my medical treatment information with any individuals and sign a Release of Information Authorization Form.
FINANCIAL RESPONSIBILITY: I understand that I am financially responsible for all services provided. I also understand that my appointment may be rescheduled if I am unable to pay my balance.
Pharmacy Benefit Manager: I consent to allow my provider to access my pharmacy benefits, which are part of my insurance plan, in order to evaluate coverage for medications prescribed for me.