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Patient Registration

The document is a patient registration form for The Shappley Clinic which collects personal information such as name, address, date of birth, insurance information, and emergency contacts from new patients in order to process their registration. It requests details on the patient's medical history, insurance coverage, and designated primary care physician to assist in their care. Patients are asked to provide their signature to authorize the clinic to process insurance claims and release medical information.

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Theshappleyclinic_registrationform
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© Attribution Non-Commercial (BY-NC)
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160 views

Patient Registration

The document is a patient registration form for The Shappley Clinic which collects personal information such as name, address, date of birth, insurance information, and emergency contacts from new patients in order to process their registration. It requests details on the patient's medical history, insurance coverage, and designated primary care physician to assist in their care. Patients are asked to provide their signature to authorize the clinic to process insurance claims and release medical information.

Uploaded by

Theshappleyclinic_registrationform
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
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The Shappley Clinic

Patient Registration Form


Date: _______________ (Please Print & Complete in Full)

MRN#: _____________ Physician’s Name: _____________________

PATIENT INFORMATION
Social Security #: ____________-____________-_____________
Last Name: __________________________ First Name: __________________________ MI: _____
Address: ___________________________________________________________________________
City: __________________________ State: ___________ Zip: __________
Home Number: (_______)________-__________ Work Number: (_______)________-__________
Date of Birth: _____/_____/_____ Age: _____ Sex:  Male  Female
Marital Status:  Single  Married  Widowed  Divorced  Separated
Race:  African American  Asian  Caucasian  Hispanic  Native American  Other
If Patient is a child, lives with:  Both Parents  Mother  Father  Other: ___________
Name of Person (With Whom Child Lives With): ____________________________________________

RESPONSIBLE PARTY IF OTHER THAN PATIENT


Social Security #: ____________-____________-_____________
Responsible Party Name: ________________________________________________________________
Address: ___________________________________________________________________________
City: __________________________ State: ___________ Zip: __________
Home Number: (_______)________-__________ Work Number: (_______)________-__________
Date of Birth: _____/_____/_____ Sex:  Male  Female Relationship: __________________
Responsible Party Employer: ___________________________________________________________

PATIENT EMPLOYER INFORMATION


Employed:  Yes  No Student:  Full-Time  Part-Time
Name: _________________________________ Address: __________________________________
City: __________________________ State: ___________ Zip: __________
Main Office Phone: (_______)________-__________ Occupation: __________________________

INSURANCE INFORMATION (We require a copy of your card)


Primary Insurance: __________________________________ Copay:  Yes  No Amount: $______
Policy Holder Name: _________________________________ Relationship: ____________________
Date of Birth: _____/_____/_____ Percentage Plan Pay (example 80%): _________________________
Insurance Address: ___________________________________ Phone:(_______)________-__________
City: __________________________ State: ___________ Zip: __________
If Insurance is through an Employee, please give Employer name: _______________________________
Policy Number: ______________________________ Group Number: _______________________
SECONDARY INSURANCE INFORMATION (We require a copy of your card)
Primary Insurance: __________________________________ Copay:  Yes  No Amount: $______
Policy Holder Name: _________________________________ Relationship: ____________________
Date of Birth: _____/_____/_____ Percentage Plan Pay (example 80%): _________________________
Insurance Address: ___________________________________ Phone:(_______)________-__________
City: __________________________ State: ___________ Zip: __________
If Insurance is through an Employee, please give Employer name: _______________________________
Policy Number: ______________________________ Group Number: _______________________

REFERRED BY:
Referring Physician: _________________________________ Phone:(_______)________-__________
If not referred by a physician, how did you hear about our office:
 Web Page  Yellow Pages  Friend/Family  Radio  Insurance Directory
 TV  Emergency Room  Newspaper  Other: ________________________

PRIMARY CARE PHYSICIAN NAME (if different from above)


PCP Physician: ______________________________________ Phone:(_______)________-__________

IN CASE OF EMERGENCY
Relative/Friend: ________________________________________________________________________
Home Number: (_______)________-__________ Work Number: (_______)________-__________
Relationship: _____________________________

EMERGENCY CONTACT (that does not live in your Household):


Name: _____________________________________________________________________________
Home Number: (_______)________-__________ Work Number: (_______)________-__________
Relationship: _____________________________

PHARMACY INFORMATION
Pharmacy Name: _____________________________________________________________________
Phone Number: (_______)________-__________ Fax Number: (_______)________-__________
(If Known)

The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to
the physician. I understand that I am financially responsible for any balance. I also authorize Middle Tennessee
Urology Specialist or insurance company to release any information required to process my claims.

PATIENT SIGNATURE: ____________________________________ DATE: ___________________

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