Get Uha Patient Registration Form - Ob/gyn Partners For Health

Completing the UHA Patient Registration Form online is a straightforward process designed to collect essential information for your healthcare needs. This guide provides step-by-step instructions to ensure you can fill out the form accurately and efficiently.

Follow the steps to complete the registration form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your full name in the designated fields for last name, first name, and middle initial. Ensure accuracy as this will be used for identification.
3. Next, specify your primary language spoken, allowing your healthcare provider to better communicate with you.
4. Fill in your complete address, including street, apartment number if applicable, city, state, and zip code.
5. Provide your phone numbers for home, work, and mobile. Indicate if there is another number to reach you.
6. List your employer details and current employment status, indicating whether you are full-time, part-time, a student, retired, or not employed.
7. Specify your date of birth and social security number. This information is crucial for identification and insurance purposes.
8. Provide your email address and indicate whether you agree to communicate with your provider via email.
9. Enter the name of your primary care physician, if applicable, along with your driver’s license number.
10. Select your race and ethnicity from the provided options. If you prefer, there is an option to decline to state.
11. Indicate your religious preference and marital status from the options listed.
12. If applicable, complete the responsible party information, especially if the patient is a minor or not the responsible party.
13. Fill out the insurance information sections. Include details for both primary and secondary insurance if available, along with policy holder details.
14. Enter emergency contact information for two individuals, including their relationship to you and their phone numbers.
15. If the patient is a minor, provide the information for the guardians or parents as specified in the sections provided.
16. Finally, review all the entered information for accuracy. You will then have the option to save changes, download, print, or share the completed form.

Complete your registration form online to ensure a smooth and efficient healthcare experience.