Patient Registration
PATIENT NAME:        
DATE OF BIRTH:            SEX:    M    F          SS#:  
PATIENT'S ADDRESS:  
     
PATIENT'S PHONE #:            MARITAL STATUS (SMWD):  
RESPONSIBLE PARTY:  
NAME:        
DATE OF BIRTH:            SEX:    M    F          SS#:  
ADDRESS:  
     
PHONE #:            E-MAIL:  
RELATIONSHIP TO PATIENT:            MARITAL STATUS (SMWD):  
EMPLOYER:         FT    PT         WORK #:  
EMPLOYER ADDRESS:  
     
SPOUSES NAME:  
SPOUSES DATE OF BIRTH:            SS#:  
SPOUSES EMPLOYER:         FT    PT         WORK #:  
NAME, ADDRESS & PHONE # OF NEAREST FRIEND OR RELATIVE NOT LIVING WITH YOU:  
INSURANCE NAME & ADDRESS: POLICY / ID #: SUBSCRIBER NAME & BIRTHDATE:
I authorize release of medical or hospital information by the Family Medical Center, P.A. to my insurance company(s) on behalf of myself and any dependents for whom I am authorized to grant such authority for processing insurance claims. I further authorize payment of benefits from Medicare and/or my insurance company(s) to the Family Medical Center, P.A. for services rendered by myself and/or my dependents. This assignment will remain in effect until revoked by me in writing. A photocopy of this authorization is to be considered as valid as the original..
Signature
Date