Patient Registration Form

Patient Registration Form – Register Now

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O’SHEA MEMORIAL CLINIC PATIENT INFORMATION

Today’s Date(Required)

Age:(Required)

Sex:(Required)

Patient Name:(Required)

SS#:(Required)

Address(Required)

Home #:(Required)

Cell #:(Required)

Email:(Required)

DOB:(Required)

Marital: M D S W(Required)

Primary Language:(Required)

Employer/Student:(Required)

Race:(Required)

Ethnicity:(Required)

Employer Address:(Required)

Phone #:(Required)

City:(Required)

School Name/Address:(Required)

City:(Required)

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

Yes

Unknown

INSURANCE INFORMATION

Please hand your card to the receptionist to be scanned

Insured Name (Policy Holder):(Required)

Relationship:(Required)

D. O. B.(Required)

SS#:(Required)

Primary Insurance:(Required)

Policy #:(Required)

Group #:(Required)

I.D. #:(Required)

Is this insurance through an employer?(Required)

Yes

Employer Name:(Required)

Address:(Required)

Phone #:(Required)

Secondary Insurance:

Insured Name:

Policy #:

Group #:

I.D. #:

PRIMARY REPSONSIBLE BILLING (GUARANTOR) PARTY

Name:

Relationship:

Phone #:

DOB:

SS#:(Required)

Address

Employer:(Required)

Address:

PhoneEmployer Phone # :

City:

State:

SECONDARY REPSONSIBLE BILLING (GUARANTOR) PARTY

Name:

Relationship:

Phone #:

DOB:

SS#:(Required)

Address

Employer:(Required)

Address:

PhoneEmployer Phone # :

City:

State:

EMERGENCY CONTACT

Emergency Contact Name:(Required)

Relationship:(Required)

Address:(Required)

Phone #:

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.

Responsible Party Signature:(Required)

Witness:(Required)

Date:

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:

Name:

Relationship:

Phone #:

Address

Name:

Relationship:

Phone #:

Address

Patient/Responsible Party Signature:

Date:

Witness:

Date:

Witness:

Date:

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