Patient Registration Form (eCW) PATIENT INFORMATION Dr. Miss Mr. Mrs. Ms. Sir Patient’s Name (Last)_________________________ (First)______________(MI)______ Previous Name________________________ Address, City, State, ZIP________________________________________________________________________________________ Home Phone _______________________ Cell No. ____________________ Work Phone _____________________ Ext. __________ Primary Care Provider (PCP) ______________________________________ Referring Provider ______________________________ Rendering Provider Name (this practice) _____________________________ Date of Birth MM______/DD ______/YYYY___________ E-Mail Address _________________________________________________ Permission to Contact via Email Race American Indian/Alaska Native Ethnicity Hispanic or Latino Language English Marital Status Asian Native Hawaiian/Pacific Islander Not Hispanic or Latino Spanish Indian Married Japanese Single - Social Security Number Sex Declined Chinese F-Female Korean Divorced - Black/African American French Widowed 1 – Full-Time Student Status F – Full-Time Student 2 – Part-Time German No Other Declined Transgender Russian Other _______________ Legally Separated Partner __________________________________ 3 – Not Employed P – Part-Time Student Hispanic M-Male Employer Name Employment Status White Yes 4 – Self-Employed 5 – Retired 6 – Active Military N – Not a Student Emergency Contact Name Phone Number Emergency Contact Relationship to Patient__________________________________ Guardian Address Line 1 _______________________________________________________________________________________________ City, State, ZIP ____________________________________________________ Do you have a living will? Yes No Home Phone _______________________ Work Phone _____________________ Ext. ______ Referring Provider Name_______________________________________________________________________________________ (information used for patient balance statements) RESPONSIBLE PARTY INFORMATION Responsible Party Another Patient Guarantor Responsible Party Name (Last) Self ___ (First) Guarantor Account Number _____________________________ Date of Birth Social Security Number Check here if information is same as patient - - (MI) ____________ MM _________/DD _________/YYYY___________ Telephone __________________________ Sex F - Female M - Male E-Mail Address ___________________________________________________________________ Permission to Contact via Email Y N Address, City, State, ZIP Employer Employer Phone Number (provide your insurance card to the front desk at check-in) PRIMARY INSURANCE INFORMATION Insurance Company/Phone Number (_______) Name of Insured Patient Relationship to Insured Subscriber ID (Policy Number) Group ID Effective Date Copay Amount Termination Date___________________ Date of Birth MM_______/DD _______/YYYY______ (provide your insurance card to the front desk at check-in) SECONDARY INSURANCE INFORMATION Insurance Company/Phone Number ( Name of Insured Patient Relationship to Insured Subscriber ID (Policy Number) Effective Date ) Group ID Termination Date___________________ Copay Amount Date of Birth MM_______/DD _______/YYYY______ (check all that apply) HOW DID YOU LEARN ABOUT US? Referring Provider Family/Friends Website Search Engine Google + Online Profile Facebook D Magazine Other Social Media Other Physician Profile Living Well Magazine HealthGrades or Vitals Other I agree that the information supplied on this form is accurate and up-to-date to the best of my knowledge. Patient (or Responsible Party) Signature ©HCA, Inc. 2011 Date Print Form