Registration Form

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Registration Form

Today’s Date Primary Care Provider

Primary Care Provider

Patient’s Last Name:

Marital Status:

Single Mar Div Sep Wid

Social Security #:

Maiden Name:

Birth Date:

Age:

Sex:

M F

Home Phone #:

Alternate phone:

Emergency Contact:

Emergency Contact #:

Occupation:

Employer:

Employer phone #:

Referral Source:

Email:

INSURANCE INFORMATION

Please give your insurance card to the receptionist

Person responsible for bill:

Birth date:

Address (if different):

Home phone #:

Occupation:

Employer:

Employer address:

Employer phone #:

Is this patient covered by insurance?

Yes No

Please indicate primary insurance:

Subscriber’s Name:

Subscriber’s SS#:

Birth Date:

Group #:

Policy #:

Co-payment:

Patient’s relationship to subscriber:

Self Spouse Child Other

Name of secondary Insurance if applicable:

Subscriber’s Name:

Group #:

Policy #:

Patient’s relationship to subscriber:

Self Spouse Child Other

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 Dr. Shamsi or insurance company to release any information required to process my claims.

Date

Patient / Guardian Signature: