NEW PATiENT REGISTRATION New Patient short Form (#14) Patient InformationInsurance InformationInsurance Information Client Confidential Information FormToday's DateLast Name :First Name :Middle Initial:Age:Date of Birth:Gender: M F TMarital Status:- Select -SingleMarriedDivorcedSeparatedOtherRace:Address: City:State :Zip Code :Cell Phone:Work Phone:Home Phone:Email :Refereed by:PreviousNextInsurance InformationInsurance Company :Name of Insured:Insured Date of Birth :Relationship of Insured :Holder DOB :Social Security # Policy #Group #Policy Holder:Co-Pay: $Deductible: $Address (if different) :City :State :zip :Please attach a copy of your state picture identification AND a copy of your insurance card here. If not,please attach under the messaging tab in the Patient Ally Portal, via our secure email address at: info@ufirsthealthcare.org OR attach under the Book Appointment tab on our web site at :www.ufirsthealthcare.org for any difficulties, please call our office: 833-583-4778. INSURANCE AUTHORIZATION AND ASSIGNMENT: I understand that I am responsible for all charges ncurred by me and all charges not allowed by my insurance company. I authorize the release of medical information necessary to process my claims. I authorize payment of any assigned medical benefits to my provider directly.DateDrivers License / State ID Front Card :Choose File Drivers License / State ID Back Card :Choose File Front Insurance Card :Choose File Back Insurance Card :Choose File PreviousNextLegal Representative of PatientIf the patient is not a minor or does not require legal representation, please skip this part.Legal Representative Last Name:Middle Name :First Name :Relationship : CHILD SPOUSE GUARDIAN HEALTH CARE POA SELFAddress :City :State :Zip Code :Phone :Email : Previous
