Get The Ben And Catherine Ivy Center For Advanced Brain Tumor

Filling out the registration form for The Ben And Catherine Ivy Center For Advanced Brain Tumor can be an essential step in accessing the medical assistance you need. This guide provides a clear and supportive walkthrough of each section of the form to ensure a smooth and efficient process.

Follow the steps to successfully complete the registration form.

1. Press the ‘Get Form’ button to obtain the registration form and open it in the designated digital document interface.
2. Select the appropriate registration option for your situation, indicating whether you are a new patient or updating your information.
3. Fill in the patient information section with your details, including your social security number, full name, maiden name (if applicable), street address, city, state, and zip code.
4. Provide your emergency contact's name and phone number. Make sure to include both your home and alternate phone numbers for immediate communication.
5. Select an appropriate gender option, and indicate your marital status by checking the appropriate box.
6. Enter your date of birth and indicate if you are a smoker, non-smoker, or previous smoker, along with any applicable race checkboxes.
7. Complete the employer information section by providing your employer's name, address, and occupation, along with your student status as full-time or part-time.
8. Fill in your primary insurance information, including the insurance company name, relationship to the subscriber, subscriber's name, and associated copay details.
9. If applicable, provide the secondary insurance details following the same format as the primary insurance section.
10. Indicate who is responsible for the remaining balance on your account, providing their details as necessary.
11. Review the patient or guarantor certification statement, and ensure you understand that it confirms the information is true and may involve payment responsibilities.
12. Sign and date the form where indicated.
13. For the medical history form, begin by entering your name, date of birth, age, and occupation. Complete the necessary medical history sections as prompted.
14. Discuss any medical problems, surgical history, allergies, and lifestyle habits accurately for best medical advice.
15. Fill in the referring provider and primary care provider information, if necessary.
16. Finally, save any changes made to the form, and select options to download, print, or share the document as required.

Complete your registration form online today to take the next step in your healthcare journey.