Registration Form

Choose an office: *

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Last Doctor seen:

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Today’s date:

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PATIENT INFORMATION

Last Name:

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First Name:

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Middle Name:

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Title:

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Marital Status

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Is this your legal name?

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If not, what is your legal name?

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Preferred Contact method:

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Birth date:

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Age:

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Sex:

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Street address / PO Box:

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Social Security #

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Home phone #

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City:

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State:

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ZIP Code:

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Cell Phone #

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Occupation / Employer:

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Employer phone #

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Referred to clinic by:

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Other:

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Other family members seen here:

Race

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Ethnicity

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Preferred Language:

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INSURANCE INFORMATION (PLEASE GIVE YOUR INSURANCE CARD TO THE RECEPTIONIST.)

Person responsible for bill:

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Birth date:

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Home phone :

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Address (if different):

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Is this person a patient here?

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Occupation:

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Employer:

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Employer address:

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Employer phone:

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Is this patient covered by insurance?

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Please indicate primary insurance:

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Other:

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Subscriber’s name:

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Subscriber’s S.S. no.:

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Birth date:

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Group no.:

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Policy no.:

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Co-payment:

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Patient’s relationship to subscriber:

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Name of secondary insurance (if applicable):

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Subscriber’s name:

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Group no.:

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Policy no.:

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Patient’s relationship to subscriber:

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IN CASE OF EMERGENCY

Name of local friend or relative (not living at same address):

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Relationship to patient:

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Home phone #

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Work phone:

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The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Internal Medicine Associates of Jasper, P.C. or insurance company to release any information required to process my claims.

Date:

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Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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