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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