Date Received:


Family Medicine/ Pain Management Registration Form

Please select your preferred location:
 

Patient’s Information
Marital Status:  
    

 Last Name: 
 
 First Name:
 
Middle Initial:
 
Address Line 1:
 
Date of Birth:
Gender:              
 
 
Address Line 2:
 
Home Phone:
City
 
 Work Phone:
State

 
Zip Code:  
 
Cell Phone:
Race 
 
 Ethnicity:

 
Social Security #:
 
Preferred Pharmacy:
 
Driver License State and Number 
 
Occupation/Employer:

 
Email Address:
Previous Doctor:
 
Reason for Leaving: 
 
Complete List of ALL Current Medications over the past year:

Emergency Contact Information (A local person)
Last Name:
 
First Name:
 
Relationship:
 
Home Phone:
 Work Phone:

 
Cell Phone: 
 
HIPPA Disclosure (People other than yourself)
 Name:
 
 Name:

 
 Relationship:
 
 Relationship:
 
 Phone:

 
 Phone:

 
Subscriber Information Please provide all applicable insurances. Not providing all the insurance information will result in a delay in making your first appointment. 
Last Name:
 
 First Name:
 
 Middle Initial:
 
 Address Line 1:
 
 Date of Birth:

 
 Gender:
 Address Line 2:
 
 Home Phone:
 City:
 
 Work Phone:
 State:
 
 Zip Code:
 
 Cell Phone:
 Social Security #:
 
 Email Address:
 Primary Insurance Company:
 
 Subscriber ID Number:
 
Group Number on Insurance Card:  
 
 Phone # on Back of Card:
Secondary Insurance Company: 
 
 Subscriber ID Number:
 
Group Number on Insurance Card
 
 Phone # on Back of Card:
How did you hear about us? Check One
                                                                     
                                                           
 
CONSENT FOR EXAMINATION, MEDICAL TREATMENT AND CONDITIONS OF EXAMINATION
Consent is hereby given to perform any and all examinations, tests, procedures, and treatments necessary and/or advisable; and in an emergency, without the presence of parents or responsible adults. I hereby authorize examination and treatment of the above-named patient by the physicians and physician extenders employed by Preferred Medical Group. I realize that the practice of medicine is not an exact science, and I acknowledge that no guarantees have been made to me as to the result of treatments or examination in this practice.

INFORMATION CONCERNING FILING A CLAIM WITH YOUR INSURANCE COMPANY

If we participate with your primary insurance, Preferred Medical Group will gladly file a claim for you. We will allow your insurance company up to 45 days from the date of service to pay the claim. If your insurance company fails to fully compensate Pinnacle Enterprises PC within this time frame, any unpaid balance becomes your sole responsibility.

CONSENT TO OFFICE POLICIES AND PROCEDURES
AUTHORIZATION TO FILE INSURANCE CLAIMS, TO RELEASE MEDICAL INFORMATION AND ASSIGNMENT OF BENEFITS I understand that I am financially responsible to Preferred Medical Group for the above-named patient(s). If my insurance company fails to fully compensate Preferred Medical Group, any unpaid balance becomes my sole responsibility. I agree to pay all amounts not covered or paid by a third-party payer within 30 days after notification from Preferred Medical Group and/or a billing company acting on its behalf. I agree to pay all costs of collection, including attorney’s fees and agrees to pay the legal rate of interest on the account until paid in full.

AGREEMENT AS TO CO-PAYMENTS, NON-COVERED OR NON-PAID SERVICES 
AND GUARANTEE OF PAYMENT

I understand that Preferred Medical Group cannot bill for co-payments. Any co-payments or payments for non-covered services are due at the time medical services are provided. I acknowledge that the above information is correct and that I am responsible for the balance on my account for any services not covered or not paid by my insurance plan.

 
*** Please initial:   I/WE ACKNOWLEDGE THAT I/WE HAVE RECEIVED OR REVIEWED A COPY OF THE FOLLOWING, ALL OF WHICH ARE FOUND AT www.preferredmedicalgroup.com: 1) POLICIES ON HIPAA, 2) POLICIES AND PROCEDURES, and 3) HEALTH FORM POLICIES.
 
 Patient Signature

 
Date
 
Witness Signature

 
 Date