Patient Registration

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PATIENT#

PATIENT REGISTRATION ___

YOUR PERSONAL INFORMATION

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LAST NAME:

FIRST:

MI:

STREET ADD:

HOME PHONE:

GENDER:

APT#:

WORK PHONE:

BIRTH DATE:

CITY:

CELL PHONE:

SS#:

STATE:

ZIP CODE:

EMAIL:

RACE:

ETHNICITY:

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PLEASE CIRCLE YOUR ANSWER BELOW

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MARITAL STATUS: M S D W

WORKING?: FT PT RET NOT EMPLOYED

STUDENT?: FT PT NOT A STUDENT

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WORK ADDRESS:

OCCUPATION:

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PHYSICIAN INFORMATION

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PRIMARY CARE PHYSICIAN:

REFERRING PHYSICIAN:

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CLOSEST EMERGENCY CONTACT (NOT LIVING WITH YOU)

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NAME:

RELATIONSHIP:

PHONE NUMBER/S:

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PARENT OR GUARDIAN INFORMATION
(Required if you are not the primary subscriber)

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LAST NAME:

FIRST:

RELATIONSHIP:

STREET ADDRESS – CITY, STATE, ZIP/HOME PHONE(IF DIFFERENT):

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BIRTH DATE:

SS#:

CELL PHONE:

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OCCUPATION/WORK ADDRESS:

WORK PHONE:

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INSURANCE INFORMATION

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Primary Insurance

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Insurance Name

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Policy/ID#

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Group Number

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COPAY (IF APPLICABLE) IS EXPECTED AT THE TIME OF SERVICE
Please read the following paragraph and sign below:

I hereby assign all medical/surgical benefits to which I am entitled to Rheumatology Specialists of CT for services
performed by them. This assignment will remain in effect until revoked by me in writing. I understand that I am
financially responsible for all charges whether or not said charges are reimbursed by insurance. I hereby authorize
said assignee to release all information necessary to secure the payment of said benefits. I further permit a copy of
this authorization to be used in place of the original. I also understand that if this account must be turned over to an
attorney for collections, I will be responsible for all attorney and court fees.