PATIENT REGISTRATION FORM

Name Sex

(Last) (First) (Middle)

Address Phone

(Street Address) (City) (State) (Zip)

Social Security # Birth date Age Marital Status: S M D W

Patient's Employer

(Name) (Occupation) (Address) (Phone)

Spouse's Name Spouse's Employer

In Case of an Emergency, Call (local contact please):

(Name) (Relationship to Patient)

(Address) (Home Phone #)) (Work Phone #)

Person responsible for payment

(Name if different from patient)

(Address) (City / State) (Zip) (Phone)

Responsible Party's Employer

(Name) (Address) (Phone)

Insurance Information (list in order they will be submitted)

Primary Subscriber

Policy # Group #

Secondary Subscriber

Policy # Group #

Workman’s'

Compensation:

(Employer Name) (Address) (Phone)

(Date of Accident) (Case #) (Firm) (Description)

AUTHORIZATION FOR RELEASE OF INFORMATION & ASSIGNMENT OF INSURANCE BENEFITS

I hereby authorize Internal Medicine Associates release to any company which has issued to me medical or hospitalization insurance, all information regarding treatment by said doctor and I further assign to said doctor all medical and surgical benefits payable to him/her under said policy. I further agree to pay said doctor for any charges for professional services not covered by such policy. Internal Medicine Associates may access any part of my records from St. Peter's Hospital (including treatment for alcohol or drug abuse) for continuity of care purposes and / or for the adjudication of all claims relating to payment of services connected with the hospitalization as provided by the Health Care Information Act. Records may be accessed in hardcopy or by computer.

Signature Date