Ellen Jones Community Dental Center
Delmar Family Medicine
PATIENT REGISTRATION FORM
Last Name: _________________________________ First Name: ___________________________ MI: _________
Date of Birth: __________________________ Social Security Number: _____________________________________
Home Address: ___________________________________________________________________________________
Home Phone: ____________________ Work Phone: _____________________ Cell Phone: ___________________
E-mail Address: __________________________________________________________________________________
How did you hear about our office? _________________________________________________________________
Gender: ? Male ?Female Ethnicity: ?Hispanic / Latino ?Not Hispanic / Latino
Marital Status: ?Single ?Married ?Widowed ?Divorced ?Separated ?Life Partner
Race: ?White/Caucasian ?Black/ African American ?Asian ?American Indian/Alaskan Native ?Native Hawaiian or other Pacific Islander ?Other
Veteran: ?Yes ?No Primary Language: ?English ?Spanish ?Chinese ?Other
Pediatric patients ~
Mother’s Maiden name: ____________________________________________________________________________
Pediatric patients ~
Mother’s name: ___________________________________________________________________________________
Father’s name: ____________________________________________________________________________________
Sibling Information: _______________________________________________________________________________
Caregiver’s name: _________________________________________________________________________________
Caregiver’s relationship: __________________________________________ Phone No: ________________________
Pharmacy:
Local: __________________________________________________________________________________________
Mail: ___________________________________________________________________________________________
* Employment Information:
Occupation: ______________________________________________________________________________________
Employer Name: __________________________________________________________________________________
Employer Phone No: ______________________________________________________________________________
Employer Address: _________________________________________________________________________________
** Responsible Person: (if different from patient)
Last Name: _______________________________________ First Name: ____________________________________
Date of Birth: _____________________________ Telephone No: __________________________________________
Address: __________________________________________________________________________________________
Relationship to patient: __________________________________________________________________________
*** Person to contact in case of emergency: (if different from Responsible Person)
Name: ______________________________________________ Telephone No: ________________________
Relationship to patient: __________________________________________________________________________
**** Medical Insurance:
Name of Insurance: ______________________________________________________________
Member ID No: ______________________________________ Group No: ____________________________
Name of Subscriber: _________________________________________________
Date of Birth: _________________________________________________
Relationship to Patient: □ Parent □ Spouse □ Partner □ Other
***** Consent to Release Information:
I hereby authorize Delmar Family Medicine to release protected health information regarding myself or my treatment / condition to:
Name: __________________________________ Relationship: ____________________________________
Telephone No: ________________________________
******Medication Access (To allow electronic prescriptions):
I hereby authorize Delmar Family Medicine to access my medication history through RX Hub. I understand that this access will allow for Delmar Family Medicine to obtain prescription information to provide better health care to patients. This information will be used only for my medical care.
Signature: _____________________________________________________________________________________
Date: ___________________________________
******* Notice of HIPPA:
On April 14, 2003, a federal law entitled the Health Insurance Portability and Accountability Act of 1996 (HIPPA) became effective. This federal law applies to our medical practice and providers of medical care (including physicians, hospitals, pharmacies), all health plans (insurance companies), and all clearinghouses (companies that process health information, including claims for payment).
Under federal law, we have been given increased administrative responsibilities and obligations to ensure the protection and security of our patient’s Protected Health Information.
We are providing each patient with the enclosed Notice of Privacy Practices. We are required to obtain your written acknowledgement of you receipt of this notice.
By signing below, I acknowledge receipt of the Notice of Privacy Protection provided to me on this date.
The above information is true best to my knowledge. I authorize my insurance benefits be directly paid to DFM. I understand that I am financially responsible for any balance. I also authorize DFM or insurance company to release any information required to process my claims.
Signature of the patient (or person authorized to sign for patient): _____________________________________
Date: _______________________________________________________________________________________
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