Get New Patient Portal Registration Form - Dingmans Medical

Filling out the New Patient Portal Registration Form - Dingmans Medical online is a crucial step for new patients seeking to streamline their healthcare experience. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to successfully complete your registration form.

1. Click ‘Get Form’ button to access the form and open it in your document editor.
2. Begin with Section I by entering your patient information including your date of birth, last name, first name, and middle name. If you have a preferred name, please specify it in the appropriate field.
3. Provide your social security number and, if applicable, the name of your school if you are a student. Include the name of a spouse or parent if relevant.
4. Select your race and ethnicity from the provided options. This information is for statistical purposes only.
5. In Section II, fill out the insurance information. Enter the responsible party's details, including date of birth, relationship to the patient, and social security number. Additionally, provide the address and employer's information.
6. Specify your insurance company name, group number, and identification number. Include the insurance company’s address and phone number, along with the effective date of the policy.
7. If you have additional insurance, repeat the previous step for the additional policy details.
8. In Section III, indicate how you heard about Dingmans Medical. Fill in any details as prompted, such as names of referring professionals or sources of advertisement.
9. Complete the medications section in Section IV. List any medications you are currently taking along with the dosage information.
10. In Section V, respond to inquiries about recent exams and screenings applicable to your gender. Specify the dates of any relevant procedures.
11. Select your preferred communication channels for appointment reminders and results, providing relevant contact details.
12. Review the request for the disclosure of your protected health information. Indicate who, if anyone, may receive your medical information.
13. Acknowledge the financial policy details by confirming your understanding of the charges and billing process.
14. Sign the form where indicated, ensuring to date your signature and provide any necessary witness information.
15. Finally, save changes to your completed form. You may choose to download, print, or share the form as needed.

Get started by completing your New Patient Portal Registration Form online!