PINNACLE HEALTH GROUP, PA

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PATIENT REGISTRATIONNAME ___________________________________ Soc. Sec. _____________________________Date of Birth ________/________/______ Marital Status _____________________ M __ F __Race_____________________________________ Ethnicity _______________________________ADDRESS ________________________________________________________________________ CITY ______________________________ STATE ______________ ZIP ________________Home Phone _________________________ Cell Phone ____________________________E-mail ____________________________________________________________________________Occupation: ______________________________Employer: _______________________________Address ________________________________________City ___________ State_____ Zip _______Work Phone __________________________ Alt. Phone ____________________________Spouse/Parent (if applicable) _______________________________________________________Address ________________________________________________________________________Phone _______________________ Alt. Phone __________________________________Referred By _____________________________________________________________________Primary Care Physician (Other physicians who care for you) ______________________________EMERGENCY CONTACT __________________________________________________________Relationship __________________________ Phone _____________________________________Address ________________________________________________________________________Preferred Pharmacy Name and Phone: ________________________________________________Preferred form of contact: ___ e-mail ___ PhoneAUTHORIZATION TO RELEASE MEDICAL INFORMATION AND ASSIGNMENT OF BENEFITS I authorize the release of any medical information necessary to process this claim. I permit a copy of this authorization to be used in place of the original. Date ______________________ Signature________________________________________I hereby authorize Vein, Heart and Vascular Institute to apply for benefits on my behalf for covered services rendered. I request that payment from my insurance company(s) be made payable to Vein, Heart and Vascular Institute or to theparty who accepts assignment. I certify the information I have provided about my insurance is correct. Date ______________________ Signature _______________________________________I understand that it is my responsibility to understand and know what my insurance will and will not pay for and that I am financially responsible for all non-covered services at the time services are rendered. I am also responsible for all co-pays and deductibles at the time services are rendered. Date _______________________ Signature _____________________________________ ................
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