Patient Registration Form

PATIENT REGISTRATION FORM (2 pages)

DATE
_______________     TIME  _______________     REASON FOR VISIT
___________________________________

REFERRING PHYSICIAN _______________________

PATIENT  INFORMATION

PATIENT
NAME ___________________________________________________________________________________________       DATE OF BIRTH  ________________________

                                    First                                                                    Middle
Initial                                         Last

SS#  ___________________________________    AGE
_____________                     SEX  _______________                PRIMARY CARE PHYSICIAN  _______________________________

HOME
ADDRESS
__________________________________________________________________________________________________________________________________

                                                Street
Address                                                                                                                                                              City                                       State                                    Zip

E-MAIL
ADDRESS __________________________________________________________________________________________________________________________________

HOME
PHONE  ________________________________                      WORK PHONE  _________________________________           CELL PHONE
__________________________________

EMERGENCY
CONTACT
____________________________________________________________________________________________________________________________

                                                    Name                                                                                                                                                     Phone
#                                                                                                     Relationship

EMPLOYER
______________________________________________________________________________________________________________________________________

                           Name                                                      Street
Address                                                                                                              City
                                      State            Zip                 Phone
#

Employment
Status: 
¨  Full-Time                   ¨  Part-Time                  ¨  Not Employed             ¨
Self Employed

IS
YOUR VISIT TODAY THE RESULT OF AN ACCIDENT?       
¨
Yes       
¨  No                     IF
YES, WHAT WAS THE DATE OF YOUR
INJURY?__________________________________________

GUARANTOR INFORMATION
(Person Responsible for Bill)

GUARANTOR
NAME
_____________________________________________________________________________________       DATE OF BIRTH  _________________________

SS#  ______________________________                   RELATIONSHIP TO PATIENT  _______________________________           
SEX __________ MARITAL STATUS  _____________________

HOME
ADDRESS  __________________________________________________________________________________________________________________________________

                                                Street
Address                                                                                                                                                              City                                       State                                    Zip

HOME
PHONE  ________________________________                      WORK PHONE  _________________________________          CELL PHONE  __________________________________

EMPLOYER
______________________________________________________________________________________________________________________________________

                           Name                                                      Street
Address                                                                                                              City
                                      State            Zip                 Phone
#

PRIMARY INSURANCE
INFORMATION

INSURED’S
NAME
_________________________________________________________     DATE OF BIRTH  _____________________     SS#
_____________________________

INSURANCE
COMPANY NAME _________________________________________________     GROUP #
_______________________
POLICY #
__________________________ 

INSURANCE
COMPANY ADDRESS  ____________________________________________________________________________________________________________________

                                                                            Street Address                                                                                                                                City                                                               State            Zip

WCOMP
CASE MANAGER
NAME:_______________________________________________________________________PHONE
NUMBER:________________________________

A.  Notice
of Privacy Practices
.  The
policies and procedures of Westfield Plastic Surgery are designed to comply
with the Health Insurance Portability and Accountability Act of 1996.  I agree that the Privacy Notice of Westfield
Plastic Surgery has been made available to me.

B.  Authorization
to Treat
.  I authorize and
direct the medical practitioners of Westfield Plastic Surgery and his/her
designee to provide medical services and diagnostic services for me as they
deem necessary and appropriate. I understand that I have the right to receive
information, to request treatment, and to seek a second opinion.  Patients 18 years and younger must be
accompanied by guardian.

C.   Assignment of Insurance
Benefits.
  I hereby
assign all medical insurance benefits, to include major medical benefits to
which I am entitled, including Medicare, private insurance and any other health
plans to Westfield Plastic Surgery.  I
understand that I am financially responsible for co-payments, co-insurance,
deductibles, and any other balance not paid for by my insurance plan.

The undersigned
patient or patient’s guardian hereby acknowledges to have read, understood and
agreed to conditions set forth in the Notice of Privacy Practices,
Authorization to Treat, Assignment of Insurance Benefits, and, if applicable,
Medicare Patient’s Information.

________________________________________________________________________________________                                                                           ___________________________

Signature of
Patient or Legal Guardian                                                                                                                                                                                                                               Date

________________________________________________________________________________________                                                                           ___________________________
Printed name of Patient                                                                                                                                       
                                                                                                                       Date
of Birth of Patient

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