Get Patient Registration Form Tri-state Neurosurgical Associates - Upmc Today S Date: Patient

Completing the Patient Registration Form is an important step in ensuring efficient and effective care. This guide provides clear and supportive instructions to help you fill out the form accurately and completely online.

Follow the steps to successfully complete the Patient Registration Form

1. Press the ‘Get Form’ button to obtain the Patient Registration Form and open it in your document editor.
2. Enter your personal information in the ‘Patient information’ section, including your full name, birthdate, social security number, gender, age, and marital status.
3. Fill out your address details, including city, state, and zip code. Provide your email address and contact numbers for home, work, and mobile.
4. Complete the ‘Employer’ and ‘Occupation’ fields to give context to your employment information.
5. Identify an emergency contact by providing their name and phone number.
6. List your primary care physician's name and phone number, along with their address.
7. Indicate how you learned about the practice by circling the relevant option provided.
8. Provide details about your insurance information, including the name, copay amount, subscriber's name, and relevant contact details.
9. If applicable, complete the secondary insurance section using the same level of detail.
10. Fill in information regarding any auto or workers' compensation claims, detailing the injury description and relevant insurance details.
11. For patients under 18, provide the names and contact information of the parents or guardians.
12. Sign and date the form to authorize payment and release of medical information.
13. Document your medical history, listing medications, allergies, and any previous illnesses or treatments.
14. If applicable, provide any surgical procedures you've undergone.
15. Include family medical history and denote any relevant conditions for living or deceased relatives.
16. Record your social history, indicating tobacco and alcohol use as well as any recreational drug use.
17. Review the completed form for accuracy and save your changes. You can then download, print, or share the form as needed.

Complete the Patient Registration Form online today to ensure your information is ready for your visit.