Get Patient Registration Sheet2.doc. Form 8-k (current Report Filing) Filed 09/17/14 For The Period

Filling out the Patient Registration Sheet is a crucial step in ensuring that your medical records are accurate and up to date. This guide will walk you through each section of the form to help you provide the necessary information efficiently and correctly.

Follow the steps to complete your Patient Registration Sheet accurately.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Fill in the date at the top of the form, followed by the name and phone number of your primary care physician.
3. Enter your full legal name in the designated fields for last name, first name, and middle initial. Avoid using any nicknames.
4. Indicate your sex by circling either 'M' for male or 'F' for female.
5. Complete your address, including city, state, and zip code, followed by your email address.
6. Provide your date of birth in the specified format (mm/dd/yyyy), your age, and your social security number, if applicable.
7. List your home, work, and other contact phone numbers.
8. Fill in your employer's name and job title, also indicate your employment status.
9. If you are under 18 years old, please provide the name and relationship of your parent or guardian and their contact information.
10. Enter the details of your emergency contact, including their relationship to you and their phone number.
11. Indicate how you were referred to the clinic.
12. Complete the insurance information sections, starting with primary coverage. Include the insurance name, policy ID, group number, subscriber name, date of birth, and relationship.
13. If applicable, fill out the secondary and tertiary insurance information in the same manner as the primary. Ensure to complete all fields.
14. Review all entered information for accuracy and completeness.
15. Save your changes, download, print, or share the completed form as needed.

Complete your Patient Registration Sheet online to ensure a smooth check-in process.