RUTH HASKINS, MD, INC.

 

PATIENT REGISTRATION

 

Patient Name                                           Today’s Date                      Date of Birth                                          Age

 

Driver’s License No.                                     Place of Birth

 

Home Address                                          City                                State                         Zip

 

Mailing Address if Different                       City                                State                         Zip

 

Home Phone Number                                     Work Phone Number                                Cell Phone Number

 

Occupation                                                                      Employer’s Name

 

Employer’s Address                                  City                                State                        Zip

 

Spouse Name                                                                                  Employer

 

Primary Care Doctor

 

Whom May We Thank for Referring You to Our Practice?

 

NOTIFY IN CASE OF EMERGENCY

Name                                                                               Relationship

 

Address                                                     City                                 State                       Zip

 

Home Phone Number                                          Work Phone Number                           Cell Phone Number

 

Nearest Relative (not living with you)

 

Home Phone Number                                           Work Phone Number                          Cell Phone Number

 

FINANCIAL INFORMATION: PERSON RESPONSIBLE FOR FEES

Name                                                                                  Telephone

 

Address                                                     City                                 State                       Zip

 

Insurance Company                                                             Claim Address

 

Subscriber’s Name                          Subscriber’s Date of Birth                Subscriber’s ID#

 

Insurance ID No.:

Secondary Insurance                                                             Claim Address

 

Subscriber’s Name                          Subscriber’s Date of Birth               Subscriber’s SSN#

 

 

I hereby assign all medical and/or surgical benefits to which I am entitled, Including Medicare, private insurance, and any other plan, to Ruth Haskins, MD, Inc.  This assignment will remain in effect until revoked by me in writing.  A photocopy of this assignment is to be considered as valid as the original.  I understand that I am financially responsible for all charges whether or not paid by said insurance.  I hereby authorize said assignee to release all information necessary to secure the payment.  I hereby authorize Ruth Haskins, MD, Inc. to perform any medical treatment as deemed necessary.

 

Signed:  ______________________________ Date:  ____________________