MARIA DEAN INTERNAL MEDICINE

Registration Form

Name_____________________________________________________Sex

(Last) (First) (MI) HM______________

Address____________________________________________Phone-WK______________

(Street) (City/State/Zip)

SS#_____________________ Birthday______________ Age____ Marital Status_______

Patient’s Employer__________________________________________________________________

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

Spouse’s Name_________________________ Spouse’s Employer____________________

In Case Of Emergency Contact________________________________________________

(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 (Please list in order of submission)

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 here by authorize Maria Dean Internal Medicine to release any company which has issued me medical or hospital insurance, all information regarding treatment by said doctor and I further assign to said doctor all medical and surgical benefits payable to him under said policy. Maria Dean Internal Medicine 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 the payment of services connected with the hospitalization as provided by the Health Care Information Act. Records may be accessed in hardcopy or by computer.