Progressive Medical Associates PLLC

Available Forms

**NEW PATIENT (1) - REGISTRATION FORM **NEW PATIENT (2) - HEALTH QUESTIONNAIRE **NEW PATIENT (3) - HEALTH SCREENINGS **NEW PATIENT - MEDICARE (Age 65 + ) *ANNUAL WELLNESS (Age 65 + ) *ANNUAL WELLNESS (Under Age 65) CONTACT FORM FORGOT MY USERNAME MAKE A CO-PAYMENT ON YOUR ACCOUNT MAKE A PAYMENT ON YOUR ACCOUNT MAKE PAYMENT ARRANGEMENTS UPDATE DEMOGRAPHICS UPDATE EMAIL ADDRESS UPDATE INSURANCE INFORMATION VITALS & CO-PAY

**NEW PATIENT (1) - REGISTRATION FORM

NEW PATIENT REGISTRATION

NEW PATIENTS ONLY. Please make sure you fill out all THREE (3) forms labeled "New Patient" (see list on the left). Submit all 3 forms: NEW PATIENT (1) REGISTRATION; NEW PATIENT (2) HEALTH QUESTIONNAIRE; and NEW PATIENT (3) ANNUAL HEALTH SCREENINGS. If you are a new patient with Medicare insurance, please also complete form (4) NEW PATIENT - MEDICARE

DEMOGRAPHICS

First Name *

Last Name *

Patient Sex Assigned At Birth *

Gender

How do you choose to identify and what are your choice pronouns, if any?

Date of Birth *

SSN *

Address *

City *

State *

Zip Code *

Cell Phone *

Home Phone *

Email Address *

Enter "NONE" if you do not use Email

Marital Status *

Race *

Emergency Contact Person *

Address of Emergency Contact *

Phone # of Emergency Contact *

Relationship of Emergency Contact to You *

HEALTH INSURANCE

Do you have health insurance? *

Yes

If NO, skip to the Financially Responsible Party section. If YES, please answer the following questions regarding your primary health insurance plan.

Primary Health Insurance

Name of Primary Insurance Company?

Name of Subscriber

Who is the primary policyholder?

Birthdate of Subscriber

Primary Policyholder Date of Birth

Your relationship to the Subscriber

Self

Spouse

Child

Other

Policy ID #

Primary Insurance ID

Group #

Primary Insurance Group #

Do you have a secondary health insurance policy?

Yes

If No, Skip to Financially Responsible Party Section. If YES, please answer the following questions regarding your secondary health insurance plan.

Secondary Health Insurance

Name of Secondary Insurance Company

Name of Subscriber

Primary Policyholder

Birthdate of Subscriber

Primary Policyholder Date of Birth

Your relationship to the Subscriber

Self

Spouse

Child

Other

Policy ID #

Secondary Insurance ID#

Group #

Secondary Insurance Group #

Financially Responsible Party

Name *

Name of the person responsible for paying medical bills

Your relationship to the financially responsible person *

Self

Spouse

Child

Other

If the patient is NOT financially responsible, please answer the following regarding the financially responsible party:

Address

Address of financially responsible party (if not the patient)

Phone Number

Phone # of financially responsible party (if not the patient)

Signature

By my signature below, I confirm that I understand that my insurance coverage is a relationship between my insurance company and myself, and I agree to accept financial responsibility for charges incurred that are not reimbursed by my insurance company. I understand that I may be billed for "No Shows" or appointments not cancelled within 48 hrs prior to the appointment time.

Electronic Signature *

If patient is under the age of 18, must be signed by financially responsible party.

DATE *

mm/dd/yyyy

Click SUBMIT FORM and then complete the next form called "NEW PATIENT (2) - HEALTH QUESTIONNAIRE"

* Required field