Hospital Pre Registration Form – Fill Out and Use This PDF

NEW PATIENT PRE-REGISTRATION FORM

Please complete and bring at the time of your first appointment.

	Primary Physician: __________________________________________
Patient Demographics
Name:	___________________________________________________ Date of Birth: __________________
Address:	___________________________________________________ SSN: _________________________
City:	___________________________________________________ State: __________ Zip: __________
Home Phone	____________________Cell Phone: _________________E-mail:____________________________

How did you hear about us? __ Radio __TV __Print Ad __Friend __Insurance __Elliot ON-CALL __Other

	In case of an emergency:
Contact # 1: ________________________________		Contact #2: ________________________________
Relationship: ________________________________		Relationship: ________________________________
Home Phone ________________________________		Home Phone ________________________________
	Employment Information
Employer Name:	____________________________________________ Phone: _________________________

Employer Address: ____________________________________________ City: ___________________________

State: ____________ Zip: ___________ Occupation: _____________________________________

Guarantor Information (person financially responsible)

Name:	__________________________________________________ Relationship: ____________________
Address:	__________________________________________________ SSN: ___________________________
City:	__________________________________________________ State: _________ Zip: _____________
Home Phone	_______________________	Cell Phone: _______________________

Employer Name: _______________________________________________ Phone: __________________________

Employer Address: _____________________________________________ City: ____________________________

State: ____________ Zip: _____________

Primary Insurance (please present card for copying)

Subscriber Name:	_____________________________________________________________________________
Date of Birth:	_____________________ SSN: __________________________

Subscriber Employer: ____________________________________________________________________________

Employer Address: _____________________________________________ City: ____________________________

State: ____________ Zip: _____________

Secondary Insurance (please present card for copying)

Subscriber Name:	______________________________________________________________________________
Date of Birth:	______________________ SSN: ___________________________

Subscriber Employer: __________________________________________________________

Employer Address: ____________________________________________ City: _____________________________

State: ____________ Zip: _____________

DISCLAIMER STATEMENT

I authorize Elliot Physician network to submit claims to my insurance carrier and to release any medical information necessary to process all claims. I also authorize payment for any medical benefits to the aforementioned for all services provided until further notified for this account. I agree that I am financially responsible for any co-pay and self-pay balance at the time of service, and any balance that may be due after the claims have been submitted to my insurance.

___________________________________________________________________________________________

Patient SignatureDate

___________________________________________________________________________________________________________________

Signature of Responsible Party

Date