Patient Registration

Contact Information

Mailing Address

Physical Address

Phone #

Email Address

Veteran

Yes No

Emergency Contact

Name

Preferably someone not living in the same house.

Phone #

HIPPA

Yes No

Other Contact

Name

Phone #

HIPPA

Yes No

Additional HIPPA authorized persons

HIPPA Autorization: Persons or organizations who are authorized to make the request for my protected Health Information and/or recieve my health information.

Payment Information

Responsible Party

Birthday

Contact Information

Address

Relationship to Patient

Employer

Insurance Information

Insurance?

Medicare Medicaid Chip Private Insurance Other None

Subscriber

Policy/ID #