Jump to Content
 

Available Forms

REGISTRATION

PATIENT INFORMATION

Last, First
Street, City, State, Zip code
Please state employer above

INSURANCE INFORMATION

Enter the primary person on the insurance
Enter date if you are not the responsible person for this insurance
If above is yes.

ASSIGNMENT AND RELEASE

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

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.

* Required field