Get Ga Gastroenterology Specialists Of Dekalb Patient Registration Form

Completing the GA Gastroenterology Specialists Of Dekalb Patient Registration Form online is a straightforward process that ensures your information is collected accurately. This guide provides detailed steps to help you fill out the form with ease and confidence.

Follow the steps to easily complete the online registration form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient's full name at the top of the form. This is essential for identifying your medical records.
3. Fill in the patient's address, city, state, and zip code accurately. This information helps in confirming the patient’s location and contact details.
4. Indicate the person financially responsible for the account. If it is the patient, mark 'Self'; otherwise, provide the name and relation.
5. Enter the name of the patient's employer along with the business phone number. This is necessary for any potential insurance correspondence.
6. Provide the patient's sex, birth date, age, and social security number. Make sure to format the date correctly and use the full social security number for accuracy.
7. Complete information for the responsible party, if applicable. This includes their birth date, social security number, and contact phone number.
8. Fill in the marital status. Select from the options provided, and include the partner’s details if necessary.
9. List the pharmacy name, address, and phone number for prescription-related information.
10. Enter details about the referring physician, if applicable, including their name and contact number.
11. Provide emergency contact information, including the person's name and relationship to the patient.
12. Detail the patient's insurance information, including Medicare and Medicaid numbers, primary and secondary insurance details.
13. Read the authorization statements regarding insurance assignments and Medicare/Medicaid benefits. Ensure you understand your financial responsibilities.
14. Sign and date the form at the bottom, ensuring all required signatures are provided, especially if a parent or guardian is completing the form for a minor.
15. After filling out the form, users can save their changes, download a copy, print the document for their records, or share it if needed.

Complete your patient registration form online today for a smoother visit at GA Gastroenterology Specialists Of Dekalb.