Patient Registration
Please complete all information and bring a copy of your health insurance coverage card, medication list and COPAY DUE at time of service
Patient Information
Last Name
First Name
MI
Maiden
Date
Address
City
State
Zip
Home Phone
Cell Phone
Work Phone
Preferred
Home
Cell
Work
Date of Birth
Social Security No.
Marital Status
Single
Married
Divorced
Widowed
Separated
Race
American Indian or Alaska Native
Asian
Black or African American
Hispanic
White
Native Hawaiian
Other Race
Other Pacific Islander
Decline to answer
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Language
English
Spanish
Other
Employment Status
Full Time
Part Time
Not Employed
Self Employed
Active Duty
Full Time Student
Part Time Student
Disabled
Other
Employer
Address
Primary Care Physician - Last Name
Primary Care Physician - First Name
Phone
Last Seen
Referring Physician - Last Name
Referring Physician - First Name
Phone
Last Seen
Responsible Party (if Patient less than 18)
Relationship
In case of emergency, who should we notify?
Phone
Relationship
Does patient have a living will (advance directive)?
Yes
No
How did you hear of our office?
Email Address
Appointment Date
Insurance Information
Do you have healthcare insurance?
Yes
No
Primary
Insurance
Subscriber Last Name
Subscriber First Name
Subscriber MI
Subscriber Date of Birth
Relationship to Subscriber
Self
Spouse
Parent
Other
Subscriber's Employer
Employer Phone
Employer Address
City
State
Zip
Do you have secondary healthcare insurance?
Yes
No
Secondary
Insurance
Subscriber Last Name
Subscriber First Name
Subscriber MI
Subscriber Date of Birth
Relationship to Subscriber
Self
Spouse
Parent
Other
Subscriber's Employer
Employer Phone
Employer Address
City
State
Zip
Assigment and Authorization
ASSIGNMENT OF INSURANCE BENEFITS/AUTHORIZATION TO RELEASE INFORMATION
I hereby authorize Michael J. Barnthouse, M.D., P.C. to file insurance and assign benefits directly payable to Michael J. Barnthouse, M.D., P.C. I authorize Michael J. Barnthouse, M.C., P.C. to release any medical or incidental information that may be necessary for either medical care or processing for financial benefits. I understand insurance claims are filed as a courtesy. All balances (including balances for failure to obtain a referral) are my responsibility.
Co-pays are due at the time of service.
Failure to fulfill my financial obligation may result in my account being forwarded to an outside collection agency, which may result in additional fees and service charges. Delinquent accounts may be reported to the credit bureau. I also understand a fee will be charged for insufficient checks.
Patient Signature
– Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
Responsible Party Signature
– Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date