Adult New Patient Registration .pdf

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Original filename: Adult New Patient Registration.pdf
Author: Dave Winters

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PATIENT REGISTRATION

Patient Name: _____________________________________________________________________
FIRST

MI

Sex: M

F

LAST

Date of Birth: ______ / ______ / ______ Age: _________

Marital Status:

Single Married Divorced Widow

Address: _______________________________________________________________________________________________________________
STREET

APT #

CITY

STATE

ZIP

Home Telephone: ____________________________ Cell Phone: ____________________________ Occupation: __________________
Social Security Number: ________ - ________ - ________ Email Address: ______________________________________________
Patient’s Primary Physician: _________________________________________________ Phone: _________________________________
PRIMARY
INSURANCE

Insurance Name:

ID Number:

Group Number:

Subscriber:

Subscriber DOB:

Employer:

Relationship to Patient:

SECONDARY
INSURANCE

Insurer Phone Number:

Insurance Name:

ID Number:

Group Number:

Subscriber:

Subscriber DOB:

Employer:

Relationship to Patient:

OTHER
INSURANCE

Insurer Phone Number:

Insurance Name:

ID Number:

Group Number:

Subscriber:

Subscriber DOB:

Employer:

Relationship to Patient:

Insurer Phone Number:

Emergency Contact/Relation: _________________________________________________ Phone: ________________________________
NOTICE OF FINANCIAL RESPONSIBILITY
I understand that payment of all medical care is due at the time of service. The patient who signs this form
is responsible for any and all co-payments, deductibles, co-insurance, and/or unpaid balances not covered
by insurance. I understand that I am responsible for any costs incurred in the collection of a patient’s account
in case of default, including reasonable attorney fees and court costs.
I hereby authorize Watertown Audiology P.C. to release any pertinent information to the health insurance
carriers, and I also authorize payment directly to Watertown Audiology P.C. A photocopy of this authorization
shall be considered as effective and valid as the original.

Patient/Parent/Guardian Name (Please Print): __________________________________________________
Patient/Parent/Guardian Signature: __________________________________________________

Date: ______________________

PATIENT AUTHORIZATIONS
Please give your insurance information to our front office staff so we can make a copy for our records
AUTHORIZATION TO RELEASE MEDICAL RECORDS
I, ________________________________________ (Please Print Your Name), hereby authorize Watertown
Audiology P.C. to release protected health information (diagnosis, reports, testing and treatment) for myself or
______________________________________ (Child’s Name) to the following people:

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

The information will be handled confidentially in compliance with all applicable state and federal laws
_____________ INITIALS
NO-SHOW/CANCELLATION POLICY
I understand that it is my responsibility to notify Watertown Audiology P.C. if I am unable to keep my scheduled
appointment. Your appointment time is valuable and has been reserved specifically to you. If it is necessary to
reschedule your appointment, please provide us with 24 hours notice. An answering machine is available in our
office.
Otherwise, a late cancellation or no show fee of $25.00 for a hearing evaluation and $50.00 for a Central
Auditory Processing (CAP) Test or a balance and dizziness test will be charged. These charges are not covered
or paid for by health insurances. Payment is due at the time of your appointment.
_____________ INITIALS
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT
I have been given the opportunity to read or obtain a copy of the Notice of Privacy Practices.
_____________ INITIALS

Patient/Parent/Guardian Name (Please Print): __________________________________________________
Patient/Parent/Guardian Signature: __________________________________________________

Date: ______________________


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