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WOMEN’S SPECIALISTS PATIENT REGISTRATION
PLEASE PRINT
Legal Name: __________________________________________________ Sex: _____ Age: ____ Date of Birth: _____/_____/_____
First
MI
Last
Marital Status: ___S___M ___D ___Widowed
Preferred/Primary Language: ______________________
SS#_______-_______-_______ Address: ________________________________ Apt#____________ PO Box________________ __
City: ______________________________ State: _______ Zip: ________ Home#:_____-______-_____Cell#:_____-______-______
Employer: _______________________________ Occupation: ____________________________ Work#:_______-_______-______
Emergency Contact (Other than home):__________________________________________________________________________
Name
Relationship
Phone Number
Race: ____________________________________________ Hispanic or Latino: __________________________
Family/Referring Physician: _________________________________
INSURANCE INFORMATION:
Primary Insurance: ___________________ Co-pay:______
Secondary Insurance: ____________________ Co-pay:_____
Group#______________ Contract#:__________________
Group#_____________ Contract #:__________________
Subscriber’s Name: ____________________ DOB: _________
_________
Subscriber’s Name: ____________________ DOB:
Relationship to Patient: _______________
Relationship to Patient: _______________
*Do you have Medicare?: _____Yes _____No
**If so are you or your spouse working?: _____Yes _____ No
COMMERCIAL INSURANCE:
I hereby authorize release of information necessary to file a claim with my insurance company and ASSIGN BENEFITS
OTHERWISE PAYABLE TO ME, TO WOMEN’S SPECIALISTS, CHRISTOPHER J. ORAVITZ, M.D. I understand I am
financially responsible for any balance not covered by my insurance carrier.
*PLEASE INITIAL THE FOLLOWING STATEMENTS- ALL MAY NOT APPLY TO YOU, BUT INITIAL EACH LINE YOU
THAT YOU UNDERSTAND THEM*
1. I authorize all medical information to be released to the insurance company and payment to be made to Women’s Specialists,
Christopher J. Oravitz, M.D. ____
2. I understand payment is due at the time services are rendered, unless billable to my insurance or prior arrangements have been
made: _____
3. I understand that if I have a Master Medical policy or co-pay, I am responsible for payment at the time of service: _____
4. I understand that if I have Medicare they will not pay for any procedure that is determined unnecessary: _____
5. Consider my “One Time Authorization Agreement” to permit payment of Medicare benefits to Christopher J. Oravitz, M.D.:_____
6. I understand that if the provider’s charge exceeds the insurance payment, or if my insurance denies payment, I will be responsible
for the amount due: ____
7. I understand that if my insurance requires a referral I am responsible for obtaining it, if not I may have to reschedule: _____
In order to provide quality care to our patients, it is the policy of this office that: 1) If a patient misses any appointment without
canceling before the scheduled appointment time, we reserve the right to bill the patient for the missed appointment and the right to
dismiss the patient from this practice. 2) If a patient fails to comply with our recommended instructions or becomes abusive towards
our staff, we also reserve the right to dismiss the patient from the practice.
Signature of Patient/Parent ____________________________________________ Date ____________________________
(A copy of this signature is valid as the original)
WS
WOMEN’S SPECIALISTS PATIENT REGISTRATION
PHARMACY: ___________________________________________________________________________________
ALLERGIES: ____________________________________________________________________________________
________________________________________________________________________________________________
WOULD YOU LIKE TO SIGN UP FOR THE PATIENT PORTAL? _________YES __________NO
If yes we need your Email address: __________________________________________________________________
Signature of Patient/Parent ____________________________________________ Date ____________________________
(A copy of this signature is valid as the original)