TDII Patient Registration Updated 9/2019

PATIENT REGISTRATION FORM Date:

Last Name First Name MI Maiden Name

Mailing Address Marital Status M S W D

City

State

Zip Code Sex Male Female

Home Phone

Cell Phone

Email

Date of Birth

Social Security #

Employer

Occupation

Work Phone

American Indian or Asian Native of Hawaii or other Black or African White Two or I do not wish Race Alaska Native Pacific Island American more races to disclose

Ethnicity Hispanic or Latino Non Hispanic or Latino I do not wish to disclose

Preferred Language

Who is your primary care provider?

How did you hear about us? Driving By Employer Existing Hospital Insurance Plan Newspaper Patient

Patient Referral Physician Referral Billboard Website Unknown

What Pharmacy do you generally use?

Location? Complete this section only if the patient is a minor

Last Name First Name MI

Mailing Address Marital Status M S W D

City

State

Zip Code

Sex Male Female

Date of Birth

Relationship to Patient

Employer

Social Security #

Primary Insurance Company Effective Date Secondary Insurance Company Effective Date

Claims Mailing Address (Street or Box) Claims Mailing Address (Street or Box)

City State Zip City State Zip

Policy ID Number Group Number Policy ID Number Group #

Name of Subscriber (Policy Holder) Date of Birth Name of Subscriber (Policy Holder) Date of Birth

Subscriber Social Security Number Relationship to Patient Subscriber Social Security Number Relationship to Patient

Subscriber Employer Work Phone # Subscriber Employer Work Phone #

Subscriber Employer Address (Street or Box) Subscriber Employer Address (Street or Box)

City State Zip City State Zip

Patie

nt In

form

atio

n Re

spon

sibl

e Pa

rty

Insu

ranc

e &

Sub

scrib

er In

form

atio

n

TDII Patient Registration Updated 9/201ф

EMERGENCY CONTACT INFORMATION

Contact Name Relationship to Patient

Home Phone Cell Phone

ASSIGNMENT/CONSENT TO TREAT I certify that all information provided is true to the best of my knowledge. I, the undersigned (patient or legal guardian) authorize

medical or surgical treatment to be rendered by the staff of The Doctor Is In. I understand that payment is due at the time of service, that there will be a charge for all returned checks, a finance charge of 1 ½% per month for all late payments, and that I will be

responsible for all costs incurred as a result of the delinquency of my account.

Patient/Guardian Signature Date

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. Please sign this form to acknowledge that you have received a copy of this office’s Notice of Privacy Practices.

Patient/Guardian Signature Date

COMMUNICATION CONSENT I authorize The Doctor Is In staff to leave medical information pertaining to my care by the following methods and will assume

responsibility to notify them whenever this information changes:

YES NO Home Telephone/Answering Machine Work Telephone Cell Phone/Voice Mail Fax Medical Records for referrals to another entity

If you would like to have information released to someone other than yourself, please complete the following:

YES NO Spouse: Parent: Other Names: (Please list name/relationship) Printed Name Patient/Guardian Signature Date