Patient Registration Form
Today’s Date
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PATIENT INFORMATION
Patient’s Last Name
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First
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M.I.
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Birth Date
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Age
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Sex
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Street Address
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City
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State
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Zip
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Home Phone
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Cell Phone
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Mother’s Name: (if patient is child)
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Father’s Name: (if patient is child)
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Chose clinic because / Referred to by
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PRIMARY CARE PROVIDER INFORMATION
Physician’s Name
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Clinic’s Name
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City
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INSURANCE INFORMATION
Primary Insurance
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Subscriber’s Name
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Birth Date
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Group #
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Policy #: (Premera & Regence members include Alpha Prefix)
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Subscriber’s Relationship to Patient
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Ins. Co. Phone # for Providers (usually on back of card)
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Secondary Ins: (if applicable)
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Subscriber’s Name
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Birth Date
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Policy #
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Group #
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Ins. Co. Phone #
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PAYMENT INFORMATION
Person Responsible for Bill
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Email Address
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Home Phone
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Cell Phone
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Street Address: (if different)
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City
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State
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Zip
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Employer
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Occupation
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Employer Phone
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CREDIT CARD INFORMATION TO REMAIN ON FILE (OPTIONAL)
Credit Card to be Authorized
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Name on Credit Card
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Expiration
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Credit Card Number
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CVC #
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Cardholder’s Relationship to Patient
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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 or Cell Phone
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Work Phone
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AUTHORIZATION
The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the servicer. I understand that I am financially responsible for any Patient Liability not paid by insurance.
Patient’s Name (*)
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by checking this box and typing your name above, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature.
Date (*)
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