PATIENT REGISTRATION FORM
Today’s Date: ___________________________________
Name (Last, First, MI): ____________________________
______________________________________________
Address: _______________________________________
______________________________________________
City: ____________________ State _____ Zip _________
Home Phone: ___________________________________
Cell Phone: _____________________________________
E-Mail Address: _________________________________
Social Security Number: ___________________________
Date of Birth: ___________________________________
Sex: [ ] Male [ ] Female
Is the patient a full time student? [ ] Yes [ ] No
Marital Status: [ ] Single [ ] Married [ ] Divorced
[ ] Widowed [ ] Separated [ ] Domestic Partner
EMPLOYER INFORMATION
Employer: ______________________________________
Address: _______________________________________
______________________________________________
City: ____________________ State _____ Zip _________
Work Phone: _______________________ Ext: ________
Occupation: ____________________________________
*Race: Check one:
[ ] American Indian/Alaska Native
[ ] Black/African American
[ ] Asian/Pacific Islander
[ ] White
[ ] Decline to provide [ ] Unknown
[ ] Other: ________________________
*Race: Check one: [ ] Native American [ ] Asian
[ ] Hispanic origin
[ ] Not of Hispanic origin
[ ] Decline to provide [ ] Unknown
[ ] Other: ________________________
*Language Preference: Check one: [ ] English [ ] Sign
[ ] Spanish [ ] Other:____________________
*Note: Information being requested by the federal
government for reporting purposes.
EMERGENCY CONTACT
Name (Last, First, MI): ___________________________
Address: ______________________________________
______________________________________________
City: ____________________ State _____ Zip ________
Home Phone: __________________________________
Work Phone: ___________________________________
Cell Phone: ____________________________________
Relationship to patient: __________________________
GUARANTOR INFORMATION
PRIMARY INSURANCE INFORMATION
Please complete for the person responsible for payment, Insurance Company Name: _______________________
if other than the patient.
Insurance Policy Number: ________________________
Guarantor Name (Last, First, MI):____________________ Group Number: ________________________________
______________________________________________ Subscriber Name (Last, First, MI): __________________
Relationship to Patient: __________________________
Relationship to Patient: __________________________
Social Security Number: ___________________________ Social Security Number: __________________________
Date of Birth: ___________________________________ Date of Birth: __________________________________
PHARMACY INFORMATION
SECONDARY INSURANCE INFORMATION
Local Pharmacy Name: ___________________________ Important, do you have any other medical insurance?
Address: _______________________________________ Insurance Company Name: _______________________
City: ____________________ State _____ Zip _________ Insurance Policy Number: ________________________
Phone: __________________ Fax: __________________ Group Number: ________________________________
Subscriber Name (Last, First, MI): __________________
Mail-In Pharmacy Name: __________________________ Relationship to Patient: __________________________
Address: _______________________________________ Social Security Number: __________________________
City: _____________________ State _____ Zip ________ Date of Birth: __________________________________
Phone: __________________ Fax: __________________
AUTHORIZATION FOR TREATMENT AND FINANCIAL RESPONSIBILITY
I (or designated guardian) authorize the Physician to provide treatment and to release medical information to my insurance as
may be necessary for payment of physician claims.
I (or designated guardian) hereby authorize payment directly to the Physician of the benefits otherwise payable to me but not
to exceed regular charges for physician claims. I (or designated guardian) understand that I am financially responsible to the
Physician for charges not covered by my insurance.
__________________________________________________________
PATIENT AND/OR GUARDIAN SIGNATURE
_____________________
DATE
AUTHORIZATION FOR RELEASE OF INFORMATION
I authorize my Physician to supply to another physician involved in my medical care a copy of necessary medical records
and/or test results requested by the Physician but ordered by my Primary Care Physician. I understand this is for the release of
medical information only. If I am a managed care subscriber, I authorize my Physician to allow my Managed Care Organization
access to my chart for Quality Review purposes.
__________________________________________________________
PATIENT AND/OR GUARDIAN SIGNATURE
_____________________
DATE
MEDICARE PATIENTS
MEDICARE BENEFITS (Please Sign) Patient’s certification, authorization to release information and payment request. I certify
that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any
holder of medical or other information about me to release to the Social Security Administration or its intermediaries or
carriers any information needed for physician claims and other related medical claims. I request that payment of claims be
made on my behalf for authorized benefits under my health insurance. I hereby authorize payment directly to my Physician
for insurance benefits otherwise payable to me. Payments are not to exceed the balance due of the practice’s regular charges
for these claims. I understand that I am financially responsible to my Physician for charges not covered by this authorization. I
understand that my Physician will bill HCFA using the term “signature on file” and am aware that my signature as written
below constitutes that “on file” signature.
__________________________________________________________
PATIENT AND/OR GUARDIAN SIGNATURE
_____________________
DATE
MEDIGAP BENEFITS (Please Sign) I hereby give my Physician permission to ask for Medigap payments for my medical care. I
understand that my Medigap Insurer needs information about me and my medical condition to make a decision about these
payments. I give permission for that information to go to my Medigap Insurer. I request that that payment of authorized
Medigap benefits be made to Aria Health Physician Services on my behalf for any services furnished me by my Physician. I
authorize any holder of medical information about me to release to my Medigap Insurer any information needed to determine
these benefits or the benefits payable for related services.
__________________________________________________________
PATIENT AND/OR GUARDIAN SIGNATURE
_____________________
DATE
CONSENT OF TREATMENT FOR MINOR/INCAPACITATED PATIENTS
I hereby authorize the Physician to provide medical treatment to _________________________________. The patient is
unable to consent to medical treatment because he/she is a minor child or other: _________________________________
______________________________________________
GUARDIAN SIGNATURE
_______________________________________________
NAME OF GUARDIAN
______________________________________________
WITNESS SIGNATURE
_______________________________________________
DATE