Patient Registration Form - Black River Family Health Practice

Patient Information

First Name: *

Middle Initial: *

Last Name: *

Date of Birth: *

Sex: *

Marital Status: *

Living Will: *

Last 4 of Social Security #: *

Mailing Address

Mailing Address *

Mailing City *

Mailing State *

Mailing Zip *

Physical Address

Physical Address *

Physical City *

Physical State *

Physical Zip *

Country: *

Phone: *

Alternate Phone:

Occupation/Employer:

Spouse's Name:

Date of Birth: *

Spouse's Phone: *

Emergency Contact Name:

Emergency Contact Phone: *

Email Address:

HITECH Act

Race: *

Ethnicity: *

Language

English Spanish Other

Smoking Status: *

Mother's Maiden Name (pediatric patients only):

If Under 18 years of age:

Mother's Name

Mother's Last 4 of Social Security #:

Mother's Phone:

Mother's Address

Mother's City

Mother's State

Mother's Zip

Father's Name

Father's Last 4 of Social Security #:

Father's Phone:

Father's Address

Father's City

Father's State

Father's Zip

Insurance/Medicare/Medicaid Assignment of Benefits & Information Release

I hereby authorize direct payment of surgical/medical benefits to Black River Health Services, Inc. for services rendered. I understand that I am financially responsible for any balance no covered by my insurance.

I request payment of authorized Medicare/Medicaid benefits on my behalf for any services furnished me by Black River Health Services, Inc. I authorize any holder of medical and other information about me to release to Medicare/Medicaid and its agents any information needed to determine these benefits for related services.

I authorize Black River Health Services, Inc. to release or receive any medical or incidental information about me that may be necessary for either medical care or processing of insurance claims.

Initials *

Parental consent for minors under 18 years

I hereby grant permission for my child to be evaluated by the provider and receive appropriate treatment including sutures and medications as deemed necessary (in my absence).

Initials *

Patient or Authorized Signature

Initials *

Date: *