Patient Registration Information Form

Patient Registration Information

(e.g., Maiden Name)

Primary Care Provider

Referring Provider (if different than PCP)

Responsible Party:

(STATEMENT WILL BE ADDRESSED TO RESPONSIBLE PARTY)

Address of Responsible Party:

Emergency Contact

Address of Emergency Contact:

RELEASE OF PERSONAL  INFORMATION TO THE PATIENT'S DESIGNEES

ASSIGNMENT OF INSURANCE BENEFITS

The undersigned hereby authorizes the release of any information relating to all claims for benefits submitted on behalf of myself and/or dependats. I further expressly agree and acknowledge that my signature on this document authorizes my physician to submit claims for benefits, for services rendered or for services to be rendered, without obtaining my signature on each and every claim to be submitted for myself and/or my dependants and that I will be bound by this signature as though the undersigned had personally signed the particular claim.

(authorized signature of subscriber)
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