PATIENT
REGISTRATION FORM
Worker’s Comp Y__
N__ Auto Accident Y__
N__ Personal Injury Y__ N__
Last Name:_____________________________________ First Name:________________________ M.I:___
Mailing
Address:_________________________________ City:
Home Phone:
(______)_______--___________________ Work Phone:
(_______) ________--__________
SSN:________________
DOB:______________________ Driver’s
License #:_______________ Sex: M F
Marital
Status: S M W
D O Spouse’s Name____________________________
Employer:______________________________________ Occupation:______________________________
Employer
Address:_________________________________________________________________________
Person to
notify in case of emergency:________________________________________________________
RACE: ETHNICITY:
q R1 American Indian or Alaskan Native __ E1
Hispanic or Latino
q R2 Asian __ E2
Non-Hispanic or Non Latino
q R3 Black or African American
q R4 Native Hawaiian /Other Pacific Islander
q R5 white
q
R9 Other Race
Primary Insurance: ______________________________ Subscriber:_______________________________
SSN#:__________________________________________ Relationship:_____________________________
Claims Address:_________________________________ ID#:_____________________________________
City:
Telephone: (_______)
_______--___________________ Extension:________________________________
Secondary Insurance:_____________________________ Subscriber:_______________________________
SSN#:__________________________________________ Relationship:_____________________________
Claims Address:_________________________________ ID#:_____________________________________
City:
Telephone: (_______)
_______--___________________ Extension:________________________________
Industrial
Carrier:________________________________ Adjustor:_________________________________
Claims
Address:__________________________________ Claim#:______________ Date of Injury:_______
City:
Attorney
Information:_____________________________ Phone#__________________________________
Case#/Other
information:___________________________________________________________________
Assignment of Benefits –
Financial Agreement
I hereby give authorization for payment of insurance benefits to be made directly to SPINAL DIAGNOSTICS AND TREATMENT CENTER and RICHARD DERBY, M.D. APC, for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by insurance. In the event of default, I agree to pay all costs of collection, and reasonable attorney’s fees. I hereby authorize this healthcare provider to release all information necessary to secure payment of benefits. I further agree that a photocopy of this agreement shall be as valid as the original. In addition, I authorize the release of my records for peer review by physicians in order to ensure the highest quality of care is being provided to me.
Responsible Party:________________________________________________ Date:____________