PATIENT REGISTRATION FORM             DATE:

RESPONSIBLE PARTY
FULL NAME:
STREET ADDRESS:
APT. NO.
ZIP CODE: 4-DIGIT EXT.
CITY: STATE:
TELEPHONE:
SSN:
EMPLOYER NAME, ADDRESS AND TELEPHONE:

PATIENT'S ADDRESS (if different from Responsible party):

PATIENT
FULL NAME:
SEX: M/F: SSN:
Relationship to Ins. #1:
#2:
BIRTH DATE:
AGE: EMPLOYER:
EMP. ADDRESS & PHONE:
Referring DR.:
FAMILY DR. ADDRESS AND PHONE:
MARITAL STATUS:   S: M: W: D:
SPOUSE OR NEAREST RELATIVE:
_______________________________________________________________________________________________
INSURANCE INFORMATION

PRIMARY CARRIER:
SUBSCRIBER: POLICY #:
GROUP#: D.O.B.
CONDITION RELATED TO: Employment: Auto Accident: DESCRIPTION OF ACCIDENT:

SECONDARY CARRIER
SUBSCRIBER: POLICY #:
GROUP #: D.O.B:
DATE OF INJURY:

_______________________________________________________________________________________________
MEDICAL INFORMATION
KNOWN ALLERGIES: Does patient smoke?:
CURRENT MEDICATIONS:
_______________________________________________________________________________________________

(310) Primary Insurance Address:

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES: BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE RECEIVED A COPY OF THIS OFFICE'S NOTICE OF PRIVACY PRACTICES
 DATE: SIGNATURE: ___________________________________
I HEREBY AUTHORIZE AND DIRECT MY INSURER TO ISSUE PAYMENT CHECK(S) FOR BENEFITS DUE ME FOR THE SERVICES RENDERED BY HAND AND RECONSTRUCTIVE SURGEONS, INC. TO BE MADE DIRECTLY TO THEM. REGARDLESS OF MY INSURANCE BENEFITS, IF ANY, I UNDERSTAND I AM FINANCIALLY RESPONSIBLE FOR THE FEES FOR SERVICES RENDERED.
DATE: SIGNATURE: ___________________________________

STATEMENT TO PERMIT PAYMENT OF MEDICARE BENEFITS TO PROVIDER, PHYSICIAN AND PATIENT
I CERTIFY THAT THE INFORMATION GIVEN BY ME IN APPLYING FOR PAYMENT UNDER TITLE XVIII OF THE SOCIAL SECURITY ACT IS CORRECT. I AUTHORIZE MY HOLDER OF MEDICAL OR OTHER INFORMATION ABOUT ME TO RELEASE TO THE SOCIAL SECURITY ADMINISTRATION OR ITS INTERMEDIARIES OR CARRIERS ANY INFORMATION NEEDED FOR THIS OR A RELATED MEDICARE CLAIM. I REQUEST THE PAYMENT OF AUTHORIZED BENEFITS BE MADE ON MY BEHALF. I ASSIGN THE BENEFITS PAYABLE FOR PHYSICIAN SERVICES TO THE PHYSICIANS OR ORGANIZATION FURNISHING THE SERVICE OR AUTHORIZE SUCH PHYSICAIN OR ORGANIZATION TO SUBMIT A CLAIM TO MEDICARE TO PAYMENT TO ME.
I REQUEST THAT PAYMENT UNDER THE MEDICAL INSURANCE PROGRAM TO BE MADE TO ME OR TO HAND AND RECONSTURCTIVE SURGEONS, INC.
DATE: SIGNATURE: _______________________________________________________