Patient Registration Form - St. Mary's Medical Center

PATIENT REGISTRATION FORMToday’s Date_____________PLEASE PRESENT INSURANCE CARDS AND DRIVER LICENSE OR PICTURE IDPatient’s Name______________________________________________________________ Birth date: _____________________(Last) (First) (MI)Street No._____________________________________________ City_________________________State______ Zip___________Home Phone__________________Cell Phone________________Other Phone_____________OK to leave message at home____Email Address___________________________________________ Married ____ Divorced ____ Single _____ Widowed _____Sex:Female___ Male____ Social Security #__________________________________Race: (Please check) o Black or African American o White o Hispanic o Other Race ___________o Other Pacific Islandero Unreported/Refused to reportEthnicity: (Please check) o Hispanic o Non Hispanic o Refused to ReportPrimary Language: __________________________________===============================================================================================Whom can we contact in Case of Emergency?_____________________________________________________________________Relationship to Patient?__________________________________Phone #__________________________Employer__________________________________________________________Occupation__________________________Employer Address____________________________________________________________Phone__________________________This section should be completed with the Insured Individual’s personal information.Primary Insurance Company____________________________ Secondary Insurance Company______________________Name of Insured_____________________________________Last FirstName of Insured____________________________________Last FirstBirthDate_______________Social Security #________________ BirthDate_______________Social Security #_____________Address_______________________________________________ Address___________________________________________City____________________________State______ ZIP________ City____________________________State______ ZIP_____Phone____________Policy Holder Name____________________ Phone____________Policy Holder Name________________Effective Date______________Policy #_____________________ Effective Date______________Policy #_________________Referring Physician__________________________________ Primary Care Physician________________________________________Pharmacy__________________________________________ Phone Number_______________________ Mail Order ______________Dependents:Name Birthdate Address Phone1. ______________________________________ _____________________ _______________________________________ _______________2. ______________________________________ _____________________ _______________________________________ _______________3. ______________________________________ _____________________ _______________________________________ _______________4. ______________________________________ _____________________ _______________________________________ _______________How did you hear about us?___Internet ____Newspaper ____Friend/Family ____Telephone Book ____Physician ___SMMC 4DOCLineSPN-03 Pg. 1 of 2 Rev. 01/2012

ADDITIONAL CONSENT TO RELEASE INFORMATIONI authorize St. Mary’s Physician Network to discuss and release medical information regarding my care and to schedule procedures tothe following family members in specific:___________________________________________________________Name___________________________________________________________Name_______________________________Relationship_______________________________RelationshipAGREEMENT TO PAYI agree to pay for all fees or my portion not covered by medical insurance for myself or the above patient at the time of service.I realize I am also responsible for full payment of fees not paid by my insurance within thirty days of notification by this office.I agree to be responsible for any fees required to collect payment for services including: attorney and court costs, collection agency fees,pre-judgment and post/judgment interest at the current legal rate. I hereby authorize insurance payment directly to St. Mary’s PhysicianNetwork.Signature_____________________________________________ Printed Name____________________________ Date___________MEDICAL RECORDS RELEASEIf it is necessary for any of my medical records, including progress notes and laboratory results, to be sent to another health careprovider for medical reasons and to facilitate timely healthcare, I authorize St. Mary’s Physician Network to do so.I also authorize the release of medical information necessary to process my claim, to my insurance company, Workman’s Compensationplan, Social Security, Medicare or Medicaid, or any representatives acting on their behalf.I further authorize the release of my medical records to any individual or organization, engaged by St. Mary’s Physician Network, or mythird party payer (insurance company), to conduct quality improvement and/or utilization review. I permit a copy of this authorization tobe used in place of the original. I hereby release St. Mary’s Physician Network for all legal liability that may arise from the disclosureof such information.Prescriptions for contraceptive uses are prescribed by your healthcare professional in his or her limited private practice capacity, not bySt. Mary’s Medical Center.Signature_____________________________________________ Printed Name____________________________ Date___________MEDICARE AUTHORIZATION (if applicable)I request that payment of authorized Medicare benefits for any services furnished to me by St. Mary’s Physician Network (or any partywho accepts assignment) be made to either me or on my behalf to St. Mary’s Physician Network. I authorize the holder of medical orother information to release to the Health Care Financing Administration (Medicare) and its agents, any information needed to determinethese benefits or benefits for related services. I further authorize St. Mary’s Physician Network to release any information needed forthis or any related Medicare/Medicaid claim to the Social Security Administration or its intermediaries or carriers.Signature_____________________________________________ Printed Name____________________________ Date___________I have received a Notice of Privacy Practice, Notice of Patients’ Rights and Responsibilities, and Notice of Financial Policy.Signature_____________________________________________Printed Name____________________________ Date___________SPN-03 Pg. 2 of 2 Rev. 01/2012