Get Physician Practices Patient Registration Form - Sentara Medical Group

Filling out the Physician Practices Patient Registration Form is an important step for ensuring that your medical information is accurate and up-to-date. This guide will provide you with clear, step-by-step instructions to help you complete the form online efficiently.

Follow the steps to complete the patient registration form online

1. Press the ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by entering your last name followed by your first name. If you have an alternate name or previous last name, include that under the ‘AKA’ field.
3. Provide your Social Security Number in the designated slots in the format of three digits, two digits, and four digits.
4. Indicate your marital status by selecting one of the options: married, single, divorced, legally separated, widowed, or life partner.
5. Enter your date of birth in the format of month, day, and year.
6. Select your gender by marking the appropriate box.
7. Fill in your home address, including city, state, zip code, and phone numbers. Include your cell phone and any alternate phone information.
8. Provide your email address and select your preferred method of communication from the options available.
9. If applicable, enter the name of your primary care physician or pediatrician. If you are a pediatric patient, list any siblings as requested.
10. Choose your race and ethnicity from the options provided in the respective sections.
11. If you require assistance due to a hearing or vision impairment, indicate this and check the appropriate box.
12. Provide details about your employer and their address, including work phone number and extension, if available.
13. If someone else is financially responsible for the bill, complete the section regarding the guarantor or legal guardian, including their relationship to you.
14. Designate an emergency contact by providing their name and relationship to you, along with their phone numbers.
15. Indicate whether your visit is due to a job-related injury or automobile accident and answer if you have an advance care plan.
16. Provide insurance information, filling out details for both primary and secondary insurance as necessary.
17. Finally, after reviewing all entries for accuracy, print or save the completed form for your records.

Complete your Physician Practices Patient Registration Form online today for a smooth healthcare experience.