LifeCare Patient Registration


 
PATIENT REGISTRATION FORM
 
SODOMA
 
DOWSWELL
 
ANDERSON
 
TODAY'S DATE
 
 
 
PATIENT NAME
 
 
RESPONSIBLE PARTY
 
 
 
MAILING ADDRESS
 
 
CITY, STATE, ZIP
 
 
 
YEAR ROUND RESIDENT SEASONAL RESIDENT ALTERNATE ADDRESS
 
 
 
HOME PHONE
 
 
CELL PHONE
 
 
WORK PHONE
 
 
 
GENDER
 
 
RACE
 
 
LANGUAGE SPOKEN AT HOME
 
 
 
DATE OF BIRTH
 
 
SOCIAL SECURITY NUMBER
 
 
 
EMAIL ADDRESS
 
 
MARITAL STATUS
 
 
 
 
PRIMARY CARE PHYSICIAN NAME/PHONE
 
 
 
PHARMACY/CROSSTREETS/PHONE
 
 
 
PRIMARY INSURANCE
 
INSURANCE CO.
 
 
 
CLAIMS ADDRESS
 
 
 
INSURED'S NAME
 
 
 
RELATIONSHIP
 
 
 
POLICY #
 
 
 
GROUP #
 
 
 
INSURED DOB
 
 
 
INSURED GENDER
 
 
 
SPECIALIST COPAY
 
 
 
SECONDARY INSURANCE
 
INSURANCE CO.
 
 
 
CLAIMS ADDRESS
 
 
 
INSURED'S NAME
 
 
 
RELATIONSHIP
 
 
 
POLICY #
 
 
 
GROUP #
 
 
 
INSURED DOB
 
 
 
INSURED GENDER
 
 
 
SPECIALIST COPAY
 
 
 
 
HOW DID YOU HEAR ABOUT THIS PRACTICE?
 
 NEWSPAPER AD  INTERNET AD  PCP REFERRED  FRIEND  YELLOW PAGES 
 
 
REFERRING PHYSICIAN
 
 
 
EMERGENCY CONTACT
 
NAME
 
EMERGENCY CONTACT
 
DOB
 
 
IS THIS CONTACT AUTHORIZED TO MAKE MEDICAL DECISIONS FOR YOU?
 
 YES  NO 
 
Assignment and Release: 1. I hereby assign my insurance benefits to be paid directly to the physician; or, if my current policy prohibits direct payment to the doctor, I instruct and direct my insurance company to make out the check to me and the rendering physician. 2. I also authorize the physician to deposit checks received on the patient's account when made out to the patient. 3. I also authorize the physician to release any information required to process claims or required in the course of my exam and treatment. 4. I hereby agree to pay my account as services are provided. If for any reason there is a balance owing on my account, I agree to pay promptly upon receipt of the monthly statement. 5. I authorize my rendering physician to initiate a complaint to the Insurance Commissioner for any reason on my behalf.
 
 
Click LifeCare Patient Registration to download the printable form