Medical office registration form



Husker Rehabilitation & Wellness Centers, P.C.REGISTRATION FORM(Please Print)Today’s date:Primary Care Physician:Referring Physician:PATIENT INFORMATIONPatient’s name:Birth date:Male □ FemaleOccupation/Employer: / /Street address:City:State/Zip:Social Security Number:Home Phone Number:Cell Number:( )( )Email: Would you like automatic appointment reminders sent via text message? □ Yes □ NoINSURANCE INFORMATION(Please give your insurance card to the receptionist.)Is this patient covered by insurance? Yes NoPlease indicate primary insurance Medicare Medicaid VA Railroad Medicare Blue Cross/Blue Shield Medica Midland’s Choice United Health Care Workman’s Comp. OtherSubscriber’s name:Birth date:Group no.:Policy or Claim no.: / /Patient’s relationship to subscriber: Self Spouse Child OtherName of secondary insurance (if applicable):Subscriber’s name:Group no.:Policy no.:Patient’s relationship to subscriber: Self Spouse Child OtherIf this is worker’s compensation, please provide employer phone number and address below:Phone: Address:IN CASE OF EMERGENCYName of local friend or relative:Relationship to patient:Phone no.:( ) ................
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