P
atient
R
egistration
F
orm
Patient Information
Patient Name
*
Date of Birth
*
Social Security No.
Address
*
City
*
State
*
Zip
*
Phone Numbers
*
Home
Cell
Business
Name of Spouse
Marital Status
Single
Married
Divorced
Separated
Widowed
Other
Gender
Male
Female
Preferred Contact Method
*
Home Phone
Cell Phone
Email
Portal (UrbanCare’s preferred method)
Race/Ethnicity (check all that apply)
Asian
Black/AfricanAmerican
Hispanic/Latino
Alaska Native
Native American
Pacific Islander
Bi-Racial
White/Caucasian
Unknown
Other
Disclosure Declined by Patient
Do you have an Advanced Directive (DNR, Living Will)?
*
Yes (please provide copy)
No
Employment Information
(Parent or Guardian employment if patient is a minor)
Employer
*
Employer Address
City
State
Zip
Phone
Occupation
Responsible Party Information
(If the patient is a minor, the person responsible for the child completes the following)
Name of Responsible Party
*
Relation to the Child
Parent(s)
Foster Parent(s)
Legal Guardian
Other
Responsible Party Address
City
State
Zip
Home Phone
Cell Phone
Work Phone
Insurance Information
Do you have Healthcare Insurance?
Yes
No
Primary Insurance Company Name
*
Copay Amount
Name of Policyholder
*
Policyholder Birthdate
*
Relationship to Patient
*
Policyholder Employer
Group Number
*
Policy ID Number
*
Do you have Secondary Healthcare Insurance?
Yes
No
Secondary Insurance Company Name
Copay Amount
Name of Policyholder
Policyholder Birthdate
Relationship to Patient
Policyholder Employer
Group Number
Policy ID Number
Emergency Contact
Name
*
Relationship
*
Address
City
State
Zip
Phone Numbers
*
Home
Cell
Release of Authorization/Assignment of Benefits/Consent for Treatment
I authorize the release of any medical information necessary to process my insurance claim(s) or as needed by my insurance carrier. I authorize and request payment of medical benefits directly to UrbanCare, LLC. I agree that this authorization will cover all medical services rendered until such authorization is revoked by me. I agree that a photocopy of this form may be used in place of the original.
I also consent for treatment for myself (any minor children in my care) by UrbanCare, LLC. I have reviewed the above information and to the best of my knowledge it is correct as written. I hereby agree to the Release of Authorization/Assignment of Benefits.
Patient or Representative 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.
Patient Name
*
Date of Birth
*
If you are not the patient, please specify your relationship to the patient
Date
*