REGISTRATION FORM - Castle Rock Urgent Care
REGISTRATION FORM
Section I: (Please Print) Date_____________________
Name:_______________________________________________________________________________________________
DOB:_______/___________/___________
I Prefer to be called: __________________________ Sex -( Male ( Female
Address:____________________________________________City:_______________State:_________Zip_______________
Phone (______)_________________ Work Phone (_____) ________________ Cell Phone (______)____________________
Social Security Number:____________________________________________
Check Appropriate Box: ( Minor ( Single ( Married ( Widowed ( Separated ( Divorced
Patient/Employer/School______________________________________ Occupation________________________________
Spouse or Parent’s Name:______________________________
Whom may we thank for referring you? ____________________________________________________________________
Person to contact in case of emergency_____________________________________ Phone__________________________
Section II Responsible Party
Relationship to Patient: ( Self ( Spouse ( Parent ( Other
Name:_____________________________________________________ Relationship to Patient: ______________________
Address:______________________________________________________________________________________________
City:_________________________________ State:__________ Zip:_____________ Phone: (____)_____________________
Section III Insurance Information
Name of Insured_________________________________DOB_______________Relationship to Patient ________________
SSN#:__________________________________________
Insurance Company_____________________________ Grp #______________________ ID#_________________________
------------ DO YOU HAVE ANY ADDIONAL INSURANCE? ( Yes ( No IF YES, COMPLETE THE FOLLOWING ------------
Name of Insured_________________________________DOB_______________Relationship to Patient ________________
SSN#:__________________________________________
Insurance Company_____________________________ Grp #______________________ ID#_________________________
Assignment and Release
I authorize the release of any information required to process claims for services rendered and herby assign my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any benefit either not covered by my insurance or remaining as the result of information stated on this form that is inadequate, incorrect, or outdated. I understand that if I have an HMO requiring that I assign a primary care provider (P.C.P.), I am responsible for assigning a provider of Founders Family Medicine Center on/prior to the date of service. I understand that there will be a $25 fee if I cancel an appointment with less than 24 hours notice. This includes arriving late to an appointment resulting in rescheduling. All balances must be paid in full before services are rendered. Our office utilizes a program called Super Scripts. This program allows us to date with a list of all medications that a patient paid for through his/her insurance company. By signing below you are consenting our office to utilize Super Scripts.
____________________________________________________________________________________
Signature of Patient or Responsible Party/Policy Holder Date
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