REGISTRATION
Patient Last Name _________________________First Name_______________________ Initial____________________________
Street Address______________________________________________________________________________________________
City____________________________________________________ State__________________ Zip________________________
Home Phone________________ Work Phone_________________ Cell Phone _____________ Email______________________
Sex M F Age______ Birth date____________ Single Married Widowed Separated Divorced
Social Security #______________________________________ Driver’s License #________________________
Insured Name _________________________________How and where did you learn about this clinic? _______________________
Last Name First Name Initial
Relationship to Insured Self Spouse Child Other
Condition/ Illness Related To Illness Employment Auto Other
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Company Name________________________________________________ Occupation_________________ |
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EMPLOYER |
Address____________________________________ Phone_______________ Full-time Part-time |
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City _________________________ State _____________ Zip __________Years Employed______________ |
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Name______________________________________ Birth date ___________SSN:_____________________ |
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SPOUSE |
Last Name First Name Initial |
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(PARENT) |
Employer Name____________________________________________ Years Employed_________________ |
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Address _______________________Phone______________________ Occupation_____________________ |
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City___________________________ State ________ Zip________________ Full-time Part-time |
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PATIENT |
Please list any and all insurance and/or employee health care plan coverage you or your spouse may have |
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INSURANCE |
Insurance Company or Health Care Plan Name__________________________________________________ |
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INFORMATION |
Policy/Group #:______________________________________ Effective Date:_______________________ |
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Name of Insured: _______________________________________ID #:______________________________ |
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SPOUSE OR |
Please list any and all coinsurance and/or employee health care plan coverage you or your spouse may have |
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SECONDARY |
Insurance Company or Health Care Plan Name__________________________________________________ |
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INSURANCE |
Policy/Group #:______________________________________ Effective Date:_______________________ |
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INFORMATION |
Name of Insured: _______________________________________ID #:______________________________ |
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Are your present symptoms or conditions related to or the result of an auto accident, work-related injury or other personal injury someone else might be legally liable for? Yes No Your Initials:__________ |
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MEDICAL |
If you answered yes, please fill out accident specific form, available at the front desk. |
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AND LEGAL |
Pregnant Yes No Pacemaker Yes No Family Physician__________________________ |
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INFORMATION |
Person to contact in emergency (Name and Phone #)_____________________________________________ |
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Attorney_________________________________________________ Telephone:______________________ |
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Address_________________________________________________________________________________ |
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LEGAL ASSIGNMENT OF BENEFITS AND RELEASE OF MEDICAL AND PLAN DOCUMENTS In considering the amount of medical expenses to be incurred, I, the undersigned, have insurance and/or employee health care benefits coverage with the above captioned, and hereby assign and convey directly to Alta Vista Chiropractic all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services rendered from such doctor and clinic. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the doctor to release all medical information necessary to process this claim. I hereby authorize any plan administrator or fiduciary, insurer and my attorney to release to such doctor and clinic any and all plan documents, insurance policy and/or settlement information upon written request from such doctor and clinic in order to claim such medical benefits, reimbursement or any applicable remedies. I authorize the use of this signature on all my insurance and/or employee health benefits claim submissions. I hereby convey to the above named doctor and clinic to the full extent permissible under the law and under the any applicable insurance policies and/or employee health care plan any claim, chose in action, or other right I may have to such insurance and/or employee health care benefits coverage under any applicable insurance policies and/or employee health care plan with respect to medical expenses incurred as a result of the medical services I received from the above named doctor and clinic and to the extent permissible under the law to claim such medical benefits, insurance reimbursement and any applicable remedies. Further, in response to any reasonable request for cooperation, I agree to cooperate with such doctor and clinic in any attempts by such doctor and clinic to pursue such claim, chose in action or right against my insurers and/or employee health care plan, including, if necessary, bring suit with such doctor and clinic against such insurers and/or employee health care plan in my name but at such doctor and clinic's expenses. Should this assignment be prohibited in part or in whole under any anti-assignment provision of my policy/plan, please advise and disclose to my provider in writing such anti-assignment provision within 30 days upon receipt of my assignment, otherwise this assignment should be reasonably expected to be effective and such anti-assignment is waived. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I have read and fully understand this agreement. |
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____________________________________________________ _____________________________ Signature of Insured / Guardian Date |