Maryland, ENT Center - Patient Registration Form
(Please print all information and completely fill out form. Thank you.)
PATIENT INFORMATION
Last Name _______________________ First Name _________________________ MI _____
Address: _____________________________________________________ Apt # ___________
City ________________________________________ State ______________ Zip ____________
Date of Birth _________________ Age ____ Sex _____ Social Security # ____________________
Marital Status □ Married □ Single Home Phone _______________ Work Phone _______________
Cell Phone ________________ Email Address _________________________________________
Place of employment ______________________________________________________________
Address __________________________________City _____________ State ____ Zip _________
Do you have health insurance through work? □ Yes □ No
REFERRING PHYSICIAN
Referring Physician Name _________________________________Phone # __________________
Address __________________________________City _____________ State ____ Zip _________
Primary Care Physician ___________________________________________________________
Reason for visit ___________________________________________________________________
Allergies ________________________________________________________________________
Medications _____________________________________________________________________
INSURANCE INFORMATION
Primary Insurance _______________________________________________________________
Complete Mailing Address __________________________________________________________
________________________________________________________________________________
Policy Holder Name ______________________________________Relationship _______________
Policy # ____________________________ Group # ______________________________________
Secondary Insurance _____________________________________________________________
Complete Mailing Address ___________________________________________________________
________________________________________________________________________________
Policy Holder Name ___________________________________Relationship __________________
Policy # ____________________________ Group # _____________________________________
PERSON FINANCIALLY RESPONSIBLE (If different from above)
Relationship to patient: □ Spouse □ Parent □ Guardian □ Next of Kin □ Other
Last Name _______________________ First Name _________________________ MI _____
Address: _____________________________________________________ Apt # ___________
City ________________________________________ State ______________ Zip ____________
Date of Birth _________________ Age ____ Sex _____ Social Security # ____________________
Marital Status □ Married □ Single Home Phone _______________ Work Phone _______________
Cell Phone ________________ Email Address _________________________________________
Place of employment ______________________________________________________________
Address __________________________________City _____________ State ____ Zip _________
CONSENT AND INSURANCE AUTHORIZATION
I hereby authorize Maryland Ear, Nose & Throat, LLC and The 33rd Street Surgery Center as their billing agent to apply for benefits on my behalf for covered services rendered. I request payment from Medicare Part B or other insurance carrier to be made directly to the provider. I certify that the information I have reported with regard to my insurance is correct and further authorize the release of any necessary information, including medical information to other insurance carriers, or above named group, or to my referring physician (in case of Medicare benefits, HCFA). This information may be revoked by my insurance carrier or me at any time in writing.
I understand and agree to be responsible for any portion of this claim that, for any reason, is not covered by my insurance. I further understand and agree to be responsible for (1) a $20 missed appointment fee, if a 24 hour cancellation notice is not given to Maryland Ear, Nose & Throat, LLC, (2) A $100 fee for any scheduled surgical procedure which is cancelled without notice or within less than one week’s notice from the date of surgery, (3) A $20 fee for any returned check.
Signature of Responsible Party ______________________________________Date ______________