STARLIFE THERAPY SERVICES
10610 Fondren Rd, Suite 128 Houston, Texas 77096 Tel : (713) 588-488 Fax: (281) 206-4664
New Patient Registration Form
Patient______
(Last Name) (First Name) (Middle Initial)
Date of Birth: ______Age: ______SSN:______
Gender: M ( ) F ( ) Marital Status: Single ( ) Married ( ) Divorced ( ) Decline ( )
Address: ______
City: ______States: ______Zip code: ______
Ethnicity: ______Race: ______Preferred Language: ______
Home Phone: ______-______Mobile Phone: ______
Employer: ______Occupation: ______
Business Address: ______
City: ______States: ______Zip code: ______
Spouse Name: ______Phone Number: ______
Are you the Primary Holder of the insurance? Yes ( ) No ( )
Primary holder’s Name: ______Date of Birth: ______Relationship: ______
Pharmacy: ______Phone Number: ______
Emergency Contact: ______Phone Number: ______
CONSENT TO MEDICAL TREATMENT
I hereby authorize Houston Medical Clinic/Universal Med-Health Centre, LLC, its employees, agents and otherwise affiliates to administer any treatment, and perform such other actions as the physician may deem necessary or advisable in my diagnosis and treatment. I am aware that the practice of medicine is not an exact science and I acknowledge that no warranty, guarantee or assurance has been made by the clinic or physician as to the result of the treatments, examination and otherwise that may be obtained.
ASSIGNMENT OF INSURANCE BENEFITS TO PROVIDER
I hereby request payment and assign any benefit due me under the terms of any policy or policies and / or under Title XVIII of the Social Security Act that may cover professional services rendered to the above named assignee.
FINANCIAL AGREEMENT
I agree to pay any balance of the charges over and above the above-mentioned benefits. It is understood by the undersigned that he/ she is financially responsible for charges not covered by the assignment.
AUTHORIZATION TO RELEASE INFORMATION
I authorize the release of any information to any insurance company or third party payor for the purpose of obtaining payment for services provided. I authorize release of any information to any physicians, skilled facility or other medical provider.
ACKNOWLEDGEMENT OF REVIEW OF NOTICE OF PRIVACY PRACTICES
I have reviewed this office’s Notice of privacy practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document.
Signature of Patient or Responsible Party: ______Date: ______
______
(Print Name of personal Representative or Responsible Party) Description of Personal Representative’s Authority