Get Patient Registration - Utmedicalcenter

Filling out the patient registration form online is an essential step in ensuring a smooth and efficient experience at Utmedicalcenter. This guide will provide clear instructions on how to complete the various sections of the form to assist you in providing the necessary information accurately.

Follow the steps to successfully complete your registration.

1. Click ‘Get Form’ button to access the form and open it for editing.
2. Fill out the personal information section, including your first name, middle initial, last name, date of birth, and Social Security Number (SSN). Ensure that you accurately provide your home address, including city, state, and zip code.
3. Provide your contact information, including home phone number, cellular phone number, and email address. This information will help us contact you as needed.
4. Indicate your marital status by selecting from the options provided: married, single, divorced, or widowed. Select the appropriate answer regarding your employment status, whether you are employed, retired, a student, or other.
5. Complete the insurance information section by filling in the primary insurance details, including the insured or cardholder's name, their relationship to you, their SSN, and their date of birth. Don't forget to bring your insurance card to the office during each visit.
6. If applicable, provide information for secondary insurance in a similar manner to that of the primary insurance.
7. Enter the emergency contact information, detailing their relationship to you, first and last name, and both home and work phone numbers.
8. Complete the information about your spouse, guarantor, or responsible party, including their name, SSN, date of birth, employer, and address. Provide the same address details as earlier for consistency.
9. Review the authorization statement that allows your physician to release information necessary for insurance claims. Ensure that you understand this authorization, as it is important for processing payments.
10. Sign the form where indicated. If you are under 18 years old, this section must be signed by a parent or guardian. Lastly, record the date of your signature.
11. Once you have filled out all sections, make sure to save your changes. You may have the option to download, print, or share the form as needed.

Complete your patient registration online today for a hassle-free healthcare experience.