635 Madison Avenue & 59th St Floor 12
New York , NY 10022
T: 212 - 486 - 7447 | F: 212 - 486 - 3557
Confidential Patient Registeration & Authorization

Welcome to Our Office

Fields in RED are required
Date
Section1 - Patient Contact Information
FIRST NAME
Middle Initial
LAST NAME
DATE OF BIRTH
EMAIL ADDRESS
Home/Mailing Address:
STREET
HOME PHONE
CITY
APT NO
CELL PHONE
STATE
ZIP
WORK PHONE
Employer:
Emergency Contact:
NAME
NAME
STREET
CELL PHONE
CITY
WORK PHONE
STATE
ZIP
RELATION
 Spouse Friend Parent Brother Sister Son Daughter Other
Section 2 - Insurance Information
INSURANCE COMPANY
ID NUMBER
NAME OF INSURED
Section 3 - Primary Care Physician
NAME
TEL
CITY
STATE
ZIP
FAX
Section 4 - How did you hear about us
 Physician Patient/Friend Internet Search Insurance Carrier Hosp. 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:
SIGNATURE:
DATE:
DATE: