WS 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)
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