Patient Registration Form My OB/Gyne
Today’s Date: ______
Patient Information: Patient’s E-mail: ______
Last Name: ______First Name: ______Middle Initial: ______
Date of Birth: ______Social Security # ______Home Phone: ______
Street Address: ______City: ______Zip Code: ______
Work Phone: ______Cell Phone: ______Patient Referred By: ______
Marital Status: _____ Single _____ Married _____ other (widow, divorced, separated) Patient PCP: ______
Spouse’s Name: ______Spouse’s Phone: ______
Employer Information:
Employer Name: ______Employer Address: ______
Occupation: ______Employer Phone: ______
Emergency Contact Information:
Last Name: ______First Name: ______Phone: ______Relationship: ______
Insurance Information:
Insurance Plan Name: ______Policy ID: ______Policy Group ID: ______
Policy Holder Name: ______Policy Holder DOB: ______Policy Social Security #: ______
Policy Holder Employer:______Policy Holder Employer Address: ______
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Please read each of the following statements carefully and sign as your authorization, understanding and agreement to each statement.
ASSIGNMENT AND RELEASE: I hereby assign my insurance benefits to be paid directly to the physician. I also authorize the physician to release any information required to process claims to my employer, prospective employer and/or insurance carrier.
Signed: ______Date: ______
MEDICARE BENEFICIARY ASSIGINMENT AND RELEASE: I request payment of authorized Medicare benefits to me or on my behalf for any services furnished me by Dr. Vidalia Butler-Poku, M.D. I authorize any holder of medical or other information about me to release to Medicare and its agents any information needed to determine these benefits or benefits for related services.
Signed: ______Date: ______
FINANCIAL OBLIGATION: I herby acknowledge that I understand there may be services provided that will not be covered by my insurance carrier, and fully understand that I am fully responsible for any and all charges not covered by my insurance carrier. I understand that payment may be requested at the time of service or I may be billed for such services subsequently.
Signed: ______Date: ______
CONSENT FOR TREATMENT: I hereby authorize the physician, nurses, medical assistants and staff to conduct such examinations, and to administer treatment and medications as they deem necessary and advisable.
Signed: ______Date: ______
ADVANCED DIRECTIVE: Do you have an advance directive (living will/power of attorney)?
______Yes ______No If yes, please provide a copy for our records.
PATIENT COMMUNICATION
May we leave a message on your voice mail or answering machine? ______YES ______NO
Is there anyone other than yourself that you authorize us to speak with on behalf of your medical care? If so, please list name and relation:
______
Please Print Name Relationship
Do you have any other communication restrictions or authorization that you would like to make known? ______
______