Oakview Medical Associates, Llc-New Patient Registration

OAKVIEW MEDICAL ASSOCIATES, LLC-NEW PATIENT REGISTRATION

Please complete fully, print in block letters, black ink & bring along with your DL/photo ID and Health Insurance card to your first appointment.

NEW PATIENT INFORMATION-
FULL NAME-First- Middle- Last-
GENDER-Circle one- Male / Female / MARITAL STATUS- Single / Married / Other
SSN# DATE OF BIRTH- EMAIL-
HOME MAILING ADDRESS-
CITY- / STATE- / ZIP-
COUNTY- / COUNTRY-
HOME PHONE-( )- - CELL-( )- - WORK( )- -
PATIENT’S EMPLOYER NAME-
EMPLOYER ADDRESS-
CITY/STATE/ZIP-
PERSON RESPONSIBLE FOR BILL/GUARANTOR-
FULL NAME-if different from above- SSN#
HOME MAILING ADDRESS-
CITY/STATE/ZIP-
PRIMARY PHONE-( ) - -
PRIMARY HEALTH INSURANCE INFORMATION-
NAME OF INSURANCE COMPANY-
POLICYHOLDER’S FULL NAME-
PATIENT’S RELATIONSHIP TO POLICYHOLDER- SPOUSE/ CHILD/ OTHER-
POLICYHOLDER’S DATE OF BIRTH-
GROUP# MEMBER ID#
INSURANCE ADDRESS-
CITY/STATE/ZIP-
SECONDARY HEALTH INSURANCE INFORMATION-
NAME OF INSURANCE COMPANY-
POLICYHOLDER’S FULL NAME-
PATIENT’S RELATIONSHIP TO POLICYHOLDER- SPOUSE/ CHILD/ OTHER-
POLICYHOLDER’S DATE OF BIRTH-
GROUP# MEMBER ID#
INSURANCE ADDRESS-
CITY/STATE/ ZIP-
IF PATIENT IS A MINOR-My child, ______has my permission to be treated in my absence at Oakview Medical Associates, LLC. I appoint ______to accompany my child for medical treatment in my absence.
EMERGENCY CONTACT-
FULL NAME- / RELATIONSHIP-
HOME/CELL PHONE- / WORK PHONE-
PREFERRED METHOD OF CONTACT-
How would you like to be contacted regarding your appointments, treatment, tests, and all other health or account/billing information provided at OAKVIEW MEDICAL ASSOCIATES, LLC? Please list & circle all that apply-
ANY METHOD: YES/ NO / HOME# / WORK# / CELL#
*Is it OKAY to leave a message regarding your Healthcare on your answering machine? YES/ NO (CIRCLE ONE)
RELEASE OF HEALTHCARE/PATIENT ACCOUNT INFORMATION- Initial one
______I do not authorize any information to be disclosed to any other parties except to me as the patient.
______I authorize the person(s) listed below to receive all health information about appointments, treatment, tests, all other health or account/ billing information provided at OAKVIEW MEDICAL ASSOCIATES, LLC. I acknowledge receipt of the OAKVIEW MEDICAL ASSOCIATES, LLC financial policy and patient responsibilities.
NAME- RELATIONSHIP- PHONE-
NAME- RELATIONSHIP- PHONE-
PATIENT SIGNATURE-- DATE—