Patient Registration

Submitted by admin on Fri, 08/12/2011 - 9:34am

Submission Date

Month

Day

Year

Submission Time

Patient's Personal Information

Last Name: *

First Name: *

Middle Initial:

Gender: *

Social Security #:

- -

Marital Status: *

Date of Birth: *

Month

Day

Year

Race: *

Ethnic Group: *

Language: *

Address: *

City: *

State: *

Zip: *

Home Phone: ( )

- -

Work Phone: ( )

- -

Cell Phone: ( )

- -

Email: *

This will be used for an additional point of contact, as well as an address for our events and newsletters.

Employer Name:

Employer Phone Number: ( )

- -

Financially Responsible Party Information

Relationship to Patient:

If you chose 'Other' Please Specify:

Last Name:

First Name:

Middle Initial:

Date of Birth:

Month

Day

Year

Social Security #:

- -

Home Phone: ( )

- -

Work Phone: ( )

- -

Cell Phone: ( )

- -

Address:

Address 2

City:

State:

Zip:

Patient's Insurance Information

Primary Insurance Name

Subscriber's Name:

Social Security #:

- -

Primary DOB:

Month

Day

Year

Relationship to Patient:

Member ID:

Secondary Insurance Name

Subscriber's Name:

Social Security #:

- -

Secondary DOB:

Month

Day

Year

Relationship to Patient:

Member ID:

Referring/Primary Physician

Name:

Address:

City:

State:

Zip:

Phone: ( )

- -

Pharmacy Information

Name: *

Address: *

City: *

State:

Zip: *

Phone: ( )

- -

Fax: ( )

- -

Emergency Contact

Name: *

Relationship: *

Address: *

City: *

State:

Zip: *

Home Phone: ( )

- -

Work Phone: ( )

- -

Cell Phone: ( )

- -

I hereby give lifetime authorization for payment of insurance benefits to be made directly to The ENT Center of New Braunfels, and any assisting physicians for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by insurance. In the event of default, I agree to pay all costs of collections and reasonable attorney’s fees. I hereby authorize this healthcare provider to release all information necessary to secure the payment of benefits. I further agree that a photocopy of this agreement shall be as valid as the original.

By placing a check mark in the check box above, you agree that all of the information that you are submitting is correct to the best of your knowledge.

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Hospital Affiliations

Guadalupe Regional Medical Center

Christus Santa Rosa Outpatient Center

Christus Santa Rosa

Central Texas Medical Center

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