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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