Charter Internal Medicine: Registration Form

Registration Form

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Date _______________________	(PLEASE PRINT)	Home Phone ________________________

Patient Information

Name ________________________________________________________ Soc. Sec. # ______________

Last Name First Name Initial

Address________________________________________________________________________________

City _______________________________________________ State _______________ Zip ____________

Sex

F Age ___ Birth Date ________

Single

Married

Widowed

Separated

Divorced

Patient Employed by: __________________________________ Occupation ________________________

Business Address ______________________________________ Business Phone ___________________

Whom may we thank for referring you? ______________________________________________________

In case of emergency who should be notified? ____________________________Phone _______________

Primary Insurance

Person Responsible for Account ____________________________________________________________

Last Name First Name Initial

Relation to Patient _______________________________________________________________________

Address (if different from patient's) __________________________________________________________

City _______________________________________________ State _______________ Zip ____________

Person Responsible Employed by: ________________________ Occupation ________________________

Business Address ______________________________________ Business Phone ___________________

Insurance Company ______________________________________________________________________

Contract # ____________________ Group # ____________________ Subscriber # ____________________

Name of other dependents covered under this plan _____________________________________________

Additional Insurance

Is patient covered by additional insurance?

Yes

Subscriber Name ____________________________ Relation to Patient __________ Birthdate ___________

Address (if different from patient's) ___________________________________________________________

City _______________________________________________ State _______________ Zip ____________

Sex

F Age ___ Birth Date ________

Single

Married

Widowed

Separated

Divorced

Subscriber Employed by: ________________________________ Occupation ________________________

Contract # ____________________ Group # ____________________ Subscriber # ____________________

Name of other dependents covered under this plan _____________________________________________

Assignment & Release

I, the undersigned certify that I (or my dependent) have insurance coverage with ______________________

___________________________________________________________ [Name of Insurance Company (ies)]

and assign directly to Dr. _____________________ all insurance benefits, if any, otherwise payable to me

for services rendered. I understand that I am financially responsible for all charges whether or not paid

by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of

benefits. I authorize the use of this signature on all insurance submissions.

_______________________________________________ ________________________ ___________

Responsible Party Signature Relationship Date