(Patient Registration Form)

Patient Information
Name:
DOB:
SSN:
Address:
City:
State:
Zip:
 Please indicate below the preferred number
to contact you, including location
(i.e. Home, Work, and Cell)
#1:
#2:
#3:
Marital Status:
Sex:
Employer:
Occupation:
Emergency Contact:
Relationship to patient:
Phone Number:
Alternate Phone:
Referring Physician:
Phone Number:
Responsible Party for Minors
Name:
DL #:
Issuing State:
Address:
City:
State:
Zip:
Primary Contact Number:
Secondary Contact Number:
Relationship to Patient:
Other Authorized Persons:
Primary Insurance Information
Policy Holders Name:
DOB:
SSN:
Relationship to patient:
Phone #:
Address:
City:
State:
Zip:
Employer:
Occupation:
Insurance Company:
Insurance Company Address:
Member ID #:
Group #:
Phone #:
Secondary Insurance Information (if applicable)
Policy Holders Name:
DOB:
SSN:
Relationship to patient:
Phone #:
Address:
City:
State:
Zip:
Employer:
Occupation:
Insurance Company:
Insurance Company Address:
Member ID #:
Group #:
Phone #:

Assignment of Benefits and Financial Agreement

I hereby consent to treatment by the physicians and/or associates of Frisco Obstetrics and Gynecology, P.A.

Consent to Treatment
Name:
Date (mm/dd/yyyy):

I hereby authorize payment of insurance benefits to be made to Frisco Obstetrics and Gynecology, PA and any assisting physicians, for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by insurance. In the event of default, I agree to pay all costs of collections and reasonable attorney fess. I also authorize Frisco Obstetrics and gynecology, PA to release any and all information necessary to secure payment of benefits. I further agree that a photocopy of this agreement or electronic signature is as valid as an original.

Electronic Signature
Name:
Date (mm/dd/yyyy):