Patient Registration Form

Patient Registration Form

O’SHEA MEMORIAL CLINIC PATIENT INFORMATION

Address(Required)
Do you have an Advance Directive (Examples: DNR, POA, Living Will, etc)?(Required)

INSURANCE INFORMATION

Please hand your card to the receptionist to be scanned

Is this insurance through an employer?(Required)

PRIMARY REPSONSIBLE BILLING (GUARANTOR) PARTY

Address

SECONDARY REPSONSIBLE BILLING (GUARANTOR) PARTY

Address

EMERGENCY CONTACT

Consent for Treatment and Release of Information: I acknowledge that I do consent to have this information used as a basis for my care and treatment, arrange for billing and payment for my care and to arrange to carry out routine healthcare. I hereby authorize my attending physician or designee to administer such treatment and medications as are necessary in that provider’s opinion. This includes medical testing
I authorize the release of any medical information necessary to my insurance company. I agree to assign benefits to clinic. If insurance does not pay for this bill, I understand and agree that I am responsible for payment. If I do not have insurance, I understand I am responsible for this bill. I certify statements above in reference to credit are true and correct and I authorize investigation if necessary.
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I give O’Shea Memorial Clinic permission to discuss and or release my information to the following person(s) this choice may be changed at any time in writing:
Address

Address

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