[gview file=”https://drmeimaris.com/wp-content/uploads/2016/08/Dr-MeimarisNewPtRegisterationWEB.pdf”]
Confidential Patient Registeration & Authorization
Welcome to Our Office
Fields in
RED
are required
Date
Section1 - Patient Contact Information
FIRST
Middle Initial
LAST
DATE OF BIRTH
E - MAIL ADDRESS
HOME PHONE
Home/Mailing Address:
STREET
CITY
APT NO
OCCUPATION
CELL PHONE
Employer:
NAME
STREET
CITY
STATE
ZIP
Emergency Contact:
NAME
CELL PHONE
WORK PHONE
RELATION
PRIMARY INSURANCE COMPANY
ID NUMBER
NAME OF INSURED
NAME
TEL
CITY
STATE
ZIP
FAX
Section 4 -
How did you hear about us
Ph
ysician
Patient/Friend
Internet Search
Insurance Carrier
Hos
p. Referral Service
(
Please indicate name)
:
AUTHORIZATION TO RELEASE INFORMATION
I hereby authorize Accent on Health Ob/Gyn,
P.C.
to release any
medical or incidental information that may be necessary, to my
insurance carrier, for either medical care or in processing
applications for financial benefit.
ASSIGNMENT OF INSURANCE BENEFITS
I hereby authorize direct payment of surgical/medical benefits
to Accent on Health Ob/Gyn,
P.C.
for the services rendered.
I
understand that I am financially responsible for any balance not
covered by my insurance and authorize Accent on Health Obgyn,
P.C.
to charge my credit card on file after notifying me in writing
of the not covered balance.
Signature
Date
Signature
Date
Work
PHONE
635 Madison Avenue &
59th St
Floor 12
New York
, NY 10022
T
212 - 486 - 7447
F
212 - 486 - 3557
ZIP
STATE
Section 2 - Insurance Information
Section 3 - Primary Care Physician
Spouse
Friend
Parent
Brother
Sister
Son
Daughter
Other