Pulmonary and Medicine Associates

Patient Information Registration Form

Last Name *

First Name *

Middle Initial

Date of Birth *

Age

Sex *

Social Security Number *

Home Phone

Cell Phone *

Work Phone

Address *

City *

State *

Zip *

Status *

Married

Widowed

Single

Separated

Divorced

Minor

Partnered

for

years

Patient/Representative EMAIL address *

Employer/ School

Occupation

Employer/ School Address

Employer/ School Phone

Whom may we thank for referring you?

In case of an emergency who should be notified?

Phone

Primary Insurance Information

Is the Responsible of the account different from patient?

Yes

Insurance Company *

Contract #/ Member ID *

Group # *

Relation to Patient

Date of Birth

Soc.Sec#

Address (if different from patient)

Phone

Secondary Insurance Information

Insurance Company

Contract #/ Member ID

Group #

Relation to Patient

Date of Birth

Soc.Sec#

Address (if different from patient)

Phone

Assignment and Release

Insurance Company: *

Doctor's Name: *

I certify that I, and/or my dependent(s), have insurance coverage with ________________ 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 authorize the use of my signature on all insurance submissions.

Pulmonary and Medicine Associates may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Please print name of Patient, Parent, Guardian, or Personal Representative *

Relationship to Patient

Date *

Signature of Patient Parent, Guardian, or Personal Representative *

Press save, to finish your signature