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Hudson’s Bay Medical Group, 100 E 33rd Street, Suite 206, Vancouver WA 98663, (360) 695-1334Registration FormPatient Information: Provider: ______________________First Name____________________________ MI________ Last Name_________________________________Mailing Address____________________________ City ____________________State _______Zip __________Date of Birth__________________________Male_______Female_______SSN__________________________Home Phone _______________________________ Cell Phone _________________________________Driver’s License___________________________ E-Mail Address: _______________________________Race/Ethnicity ______________________________ Primary Language __________________________Marital Status (please circle one): Single/ Married/ Divorced/ WidowedSpouse Name ____________________________ Phone Number _______________________________Emergency Contact Name (other than spouse) _____________________________________________Phone Number_____________________________ Relationship_________________________________Employer Information:Employer/Company Name___________________________Occupation_____________________FT/PTWork Phone Number_________________________Address____________________________________Insurance information:Please note: We bill your insurance carrier as a courtesy. Please fill out to completion. It is Hudson’s Bay’s office policy to acquire your SSN, failure to do so may result in full payment of visit at time of service.Primary Insurance:Plan Name_______________________________________Address___________________________________Policy Holders Name ______________________________________ Date of Birth _______________________ID Number _______________________________________ Group Number____________________________Relationship to Patient _____________________________ Effective Date _____________________________Secondary Insurance:Plan Name_________________________________________Address_________________________________Policy Holders Name ______________________________________ Date of Birth_______________________ID Number ______________________________________ Group Number_____________________________Relationship to Patient _____________________________ Effective Date _____________________________I certify the above information given by me is correct and true.Patient Name (PRINT) _____________________________________________ Date _____________________Patient or Legal Representative Signature _____________________________ Relationship _______________Phone Messages: It is our policy to leave brief messages regarding lab results, imaging results and appointment dates and times. We do not leave messages for abnormal results: Initial for consent_____________. 05/04/2020 ................
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