PATIENT REGISTRATION FORM
	New Patient			Work Related Injury			Date Completed _______________
	Info-Update			Auto-Accident Related			Employee Initial ________________
PATIENT INFORMATION
Name: (First, MI, Last)						Home Phone:
Address: (Street#, City, State, Zip)						Social Security #:
Sex:			DOB			Marital Status
Employer				Job Title		Work phone #:
FINANCIAL RESPONSIBILITY
Name of person financially responsible: (if patient is a minor)						Relationship to Patient:
Address: (Street#, City, State, Zip) ** If different than patient**
Phone #			DOB			Social Security #
Name and phone number of emergency contact
REFERRING PHYSICIAN INFORMATION
Referred by:						Office Phone #:
Address
Primary care or family  physician name						Office Phone#;
Adress
INSURANCE INFORMATION
Primary Insurance carrier				Group #			ID #
Policy Holder's Name (First, MI, last)				PCP Co-pay amount			Specialist Co-pay amount
Address: (Street#, City, State, Zip) ** If different than patient**
Phone #			Relationship			DOB		Sex
Employer				Social Security#			Effective date of insurance
Secondary Insurance carrier				Group #			ID #
Policy Holder's Name							Relationship to patient
______________________________________________________							______________________________
		Patient Signature						Date
INSURANCE VERIFICATION WORKSHEET
Patient Name				MegaWest Account #			Primary Insurance Carrier
Claim/Billing Address							Name of Provider Representative
Name of Policy Holder				Employer group Name/Number			Provider Service Telephone #
Effective Date of Policy				Termination Date of Policy			Co-Pay Amount
PCP Name				Effective date			Date of verification
HCE Employee name
PRIMARY CARE PRACTICES ONLY
If the PCP listed on the card or verified with a provider service representative should differ from the physician that the patient is scheduled to see, the patient MUST be notified to change.
Date patient was notified to change PCP
Additional Comments: