MIME-Version: 1.0 Content-Location: file:///C:/EA4BB24E/New_PTregistration.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Lone Star Physicians Group, P

Lone Star Physicians Group, P.A.

 

New Patient REGISTRATION FORM

   &n= bsp;           

(Please Print)

Today’s date:

PCP:

PATIENT INFORMATION

Patient’s Last name:

First:

M. I.

Preferred Name

Date of Birth:       &nbs= p; /       &nbs= p; /

 

 

 

 

Sex:       Male         Female

Street address:       &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;        Apt. #

SS. No:       &nbs= p;      -       &nbs= p;   -

P.O. Box:

City:

State:      

ZIP:

Home phone:

Preferred phone #:      Home <= span style=3D'mso-spacerun:yes'>       = 633;   Mom ‘s cell      Dad&#= 8217;s cell        OK to leave message

Mother (Legal Guardian) Name:

Occupation:

Address (if different from above):

Cell phone:

Work phone:

E mail:

Father (Legal Guardian) Name:

Occupation:

Address (if different from above):

Cell phone:

Work phone:

E mail:

Referred  by:   Insurance<= span style=3D'mso-spacerun:yes'>      Family     Friend  ___________________ Yellow pages=     Physician __________= ________ Other

Other family members seen here:

 

 

INSURANCE INFORMATION

(Please give the insurance card and driver’s license to the receptionist.)

Person responsible for bill:

Home phone no.: (             )

Address (if different):

Birth date:       &nbs= p;   /       &nbs= p; /

S.S. No.:       &nbs= p;          /       &nbs= p;   /

Occupation:

Employer:

Employer phone no.:

Employer address:

(           )

Is this patient covered by insurance?     q<= /span> Yes      q<= /span> No

q Primary Insurance

Subscriber’s name: (if different from above)

Subscriber’s S.S. No.:

Birth date:

Subscriber ID/Policy #

Group #

Co Pay

 

         /        /

        /       &nbs= p; /     =

 

 

$

Patient’s relationship to subscriber:

q Self

q Spouse

q Child

q Other

Secondary insurance:           Yes      □<= span style=3D'mso-spacerun:yes'>   No

Subscriber’s name: (if different from above)

Subscriber’s S.S. No.:

Birth date

Subscriber ID/Policy #

Group #

Co Pay

 

       &nbs= p; /        /     =

        /       &nbs= p;  /  

 

 

$

Patient’s relationship to subscriber:

q Self

q Spouse

q Child

q Other

 

IN CASE OF EMERGENCY

Name of local friend or relative (not living at same address):

Relationship to patient:

Home phone no.:

Work phone no.:

 

 

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(       &nbs= p;  )

The above information is true to the best of my kn= owledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Lone Star Physicians Group, P.A  or insurance company to release a= ny information required to process my claims.

 

Preferred E-mail address (for our office communicati= ons only):

 

 

Parent/Guardian signature:

 

Date:

 

Parent/ Guardian Name (Print):