Bethel Medical Clinic

Available Forms

AUTHORIZATION FOR RECORD RELEASE MEDICARE WELLNESS CHECKUP PRIVACY PRACTICES ACKNOWLEDGEMENT REGISTRATION S - RECONOCIMIENTO DE PRÁCTICAS DE PRIVACIDAD S - REGISTRO

REGISTRATION

Date

PATIENT INFORMATION

Name *

Last, First

Address *

Street, City, State, Zip code

Mobile phone number *

Home phone number

Date of birth *

Sex *

Marital Status *

Employer

Please state employer above

Occupation

Business phone number

INSURANCE INFORMATION

Responsible party *

Enter the primary person on the insurance

Relationship to patient

Date of birth of responsible person

Enter date if you are not the responsible person for this insurance

Name of Insurance

Subscriber ID number

Other insurance coverage? *

Yes

Insurance name

If above is yes.

ASSIGNMENT AND RELEASE

I, the undersigned certify that I (or my dependent) have insurance coverage with

Name of insurance

and assign directly to Bethel Medical Clinic all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the clinic to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

Responsible party signature *

Relationship *

Date of signature

* Required field