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 ______________