Get Hospital for Special Surgery Patient Registration Form

PATIENT REGISTRATION FORM HOSPITAL FOR SPECIAL SURGERY 535 East 70th Street NEW YORK NY 10021 MEDICAL RECORD NUMBER DATE OF VISIT HOSPITAL PHYSICIAN PATIENT S FULL NAME last first MI. DATE OF BIRTH BIRTH PLACE SOC. SEC. NUMBER RELIGION ADDRESS no. street apt city state zip code COUNTY HOME PHONE SEX RACE MARITAL STATUS TEMPORARY ADDRESS 1 CELL PHONE if applicable EMPLOYMENT If full-time student provide information on school PATIENT S EMPLOYER PATIENT OCCUPATION EMPLOYER ADDRESS no. stret city state zip code Full-Time Part-Time Retired Student RETIREMENT DATE EMP PHONE E-MAIL ADDRESS GUARANTOR The person responsible for the bill Self Spouse Parent/Guardian Other If guarantor other than self provide person s information below RELATIVES Persons to be notified in case of emergency RELATIVE 1 FULL NAME RELATIONSHIP TO PATIENT EMPLOYER OCCUPATION MEDICAL DETAIL COMPLAINT ALLERGIES REF* PHYSICIAN/ ADDRESS PRIMARY INSURANCE MEDICAID MEDICARE BLUE CROSS COMMERCIAL WORKMEN S COMP NO-FAULT INSURANCE COMPANY NAME POLICY NUMBER PHONE NUMBER ACCIDENT DATE ACCIDENT PLACE CLAIM NUMBER WCB CASE NUMBER NATURE OF ACCIDENT SECONDARY INSURANCE ASSIGNMENT AND RELEASE OF INFORMATION STATEMENT - I certify that the information given by me is correct. I understand that this information is entered into a database and I hereby authorize the sharing of such information with Hospital affiliated physicians who are responsible for my care and their offices. I hereby also authorize the release of information related to my medical care as requested by government agencies and/or insurance carriers. I hereby assign benefits to the Hospital and understand that in the absence of accepted insurance coverage I/legal guardian am responsible for full payment of services rendered* MEDICARE PATIENTS - I certify that the information given by me in applying for payment under Title XVII of the Social Security Act is correct. I understand that I am responsible for insurance deductibles on all services 20 co-insurance on ancillary services. When Medicare is deemed the secondary insurance I will follow payment terms under Hospital policies. EFFECTIVE DATE - These statements shall be efective from the date of the signature below until December 31 of the current year unless you notify HSS otherwise in writing at the address written above. DATE OF BIRTH BIRTH PLACE SOC. SEC. NUMBER RELIGION ADDRESS no. street apt city state zip code COUNTY HOME PHONE SEX RACE MARITAL STATUS TEMPORARY ADDRESS 1 CELL PHONE if applicable EMPLOYMENT If full-time student provide information on school PATIENT S EMPLOYER PATIENT OCCUPATION EMPLOYER ADDRESS no. stret city state zip code Full-Time Part-Time Retired Student RETIREMENT DATE EMP PHONE E-MAIL ADDRESS GUARANTOR The person responsible for the bill Self Spouse Parent/Guardian Other If guarantor other than self provide person s information below RELATIVES Persons to be notified in case of emergency RELATIVE 1 FULL NAME RELATIONSHIP TO PATIENT EMPLOYER OCCUPATION MEDICAL DETAIL COMPLAINT ALLERGIES REF* PHYSICIAN/ ADDRESS PRIMARY INSURANCE MEDICAID MEDICARE BLUE CROSS COMMERCIAL WORKMEN S COMP NO-FAULT INSURANCE COMPANY NAME POLICY NUMBER PHONE NUMBER ACCIDENT DATE ACCIDENT PLACE CLAIM NUMBER WCB CASE NUMBER NATURE OF ACCIDENT SECONDARY INSURANCE ASSIGNMENT AND RELEASE OF INFORMATION STATEMENT - I certify that the information given by me is correct. .