Get Salib Oncology Registration Information

This guide offers clear instructions on how to effectively complete the Salib Oncology Registration Information form online. Follow the steps below to ensure accurate submission of your registration details.

Follow the steps to complete your registration information accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by providing the date in the designated field. This should reflect the date you are filling out the registration information.
3. Enter the patient's full name in the format of last name, first name, and middle initial in the appropriate field.
4. If the patient is a minor, input the name of the responsible party and ensure that their details are complete.
5. Complete the street address, city, state, and zip code fields to provide an accurate residence location.
6. Indicate the patient's sex and enter their age and birthdate in the relevant fields.
7. Select the marital status by choosing from the given options: single, married, widowed, separated, or divorced.
8. Specify the name of the employer and business address if the patient is currently employed. Additionally, provide the occupation and business phone number.
9. Clearly state the purpose of the visit in the dedicated field to facilitate appropriate care.
10. Enter the name of the party responsible for the account and their relationship to the patient.
11. Provide the social security numbers for both the patient and spouse (if applicable) in the designated areas.
12. Indicate whether the patient has medical insurance by selecting yes or no. If yes, provide details for the primary insurer, including the contract number, group number, and subscriber number.
13. Should there be a secondary insurer, enter their information similarly as required.
14. If applicable, fill in the Medicare or Medicaid claim ID number and welfare information if relevant.
15. Choose the preferred payment method for the balance of services either at the time of service, upon receiving the first statement, or by making prior arrangements.
16. Identify an emergency contact with their phone number for any urgent matters.
17. Provide the name and phone number of the user's preferred pharmacy for reference.
18. Mention how you learned about the practice to help understand effective outreach methods for the practice.
19. Complete the assignment of insurance benefits section by signing and dating the document to authorize the release of claims information.
20. Finally, review the completed information for accuracy before saving your changes, downloading, printing, or sharing the completed form.

Take the next step and complete your registration information online today.