Get Patient Registration Form - Eastside Endoscopy Center

Completing the patient registration form online is a vital step before your visit to Eastside Endoscopy Center. This guide will help you navigate through each section of the form with clarity and ease.

Follow the steps to complete your registration form effectively.

1. Press the ‘Get Form’ button to acquire the form and access it in your preferred editor.
2. Begin filling out the patient information section. Provide your legal name, complete address including street, city, state, and zip code. Make sure to note your social security number and date of birth accurately. Choose your marital status and optionally select your race from the given options.
3. If your billing address is different from your residential address, fill in the billing address section accordingly.
4. Input your daytime phone number and evening or cell phone number. Provide the name of your family doctor along with any necessary authorization number, if applicable.
5. In the responsible party section, enter the name, date of birth, social security number, and employer information for the individual responsible for the bill.
6. Fill out the primary and secondary insurance information, including the policy holder's name, date of birth, social security number, and employer. Additionally, provide the insurance company name and the respective policy and group numbers.
7. For the emergency contact section, list the name, relationship to the patient, and daytime and evening or cell phone numbers of the designated emergency contact.
8. Review the release of benefits and information section thoroughly. Confirm your understanding of the financial responsibilities and authorizations, then sign and date the form where indicated.
9. Once you have completed all sections of the form, ensure all information is accurate then save your changes. You may download, print, or share the completed form as needed.

Complete your patient registration form online today to ensure a smooth appointment process.