Get Port City Neurosurgery & Spine Registration Form

This guide provides comprehensive instructions for completing the Port City Neurosurgery & Spine Registration Form online. By following these steps, you will be able to successfully submit your registration information, ensuring a smooth experience for your upcoming appointment.

Follow the steps to fill out your registration form with ease

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with today’s date and the date of your appointment. Ensure accuracy as this will help in coordinating your visit.
3. In the reason for visit field, provide a brief description of the purpose of your appointment.
4. Fill in the referring physician's details, including their full name and phone number.
5. Enter the patient’s information, including first name, middle/maiden name, last name, and suffix.
6. Indicate the patient’s sex by selecting either M or F.
7. Specify the patient’s race and ethnic origin by selecting the appropriate options.
8. Provide the patient’s date of birth and age.
9. Fill in marital status and primary language spoken.
10. Enter the patient’s social security number, street address or P.O. Box, city, county, state, and zip code.
11. Provide contact information, including home phone number, work phone number, cell phone number, and email address. Also, select your preferred contact method.
12. Provide employer details, including the employer's name and address.
13. If applicable, enter the spouse’s name and employment details, along with the spouse’s phone number.
14. Identify the nearest friend or relative to contact in case of emergency, along with their relationship to the patient and a phone number.
15. Complete the primary insurance details, including the insurance company name, policy holder's name and date of birth, policy ID, and group number. Don't forget to include the date of injury.
16. If applicable, also fill in the secondary insurance information using the same format as the primary insurance.
17. Review and acknowledge the authorization statement regarding the release of medical information and payment obligations.
18. Ensure that you have checked the acknowledgment for the Notice of Privacy Practices.
19. Finally, provide your signature (or that of a legal guardian) to confirm all information is correct and complete.
20. Once you have filled out the form, save changes, and if required, download, print, or share the form as needed.

Complete your Port City Neurosurgery & Spine Registration Form online today to ensure your appointment goes smoothly.