Registration Patient Information

Registration Insurance Information

Registration In Case Of Emergency

  • Registration Patient Information
  • Registration Insurance Information
  • Registration In Case Of Emergency

Registration Patient Information

Paitent's last name

First

Middle

Marital status

Is this your legal name?

Former name: If not what is your legal name?

Birth date

Age: Please enter a value between 1 and 200.

Sex

Street address

Social Security no

Phone no

State

City

Street Address

Address

ZIP Code

P.O box

Occupation

Employer

Employer phone no

Chose clinic because / Refferend to clinic by (please check one box)

Email

Registration Patient Information

Person reponsible for bill

Birth date

Address (if different)

Phone no

Subscriber's name

Subscriber's S.S. no

Group no

Policy no

Co-payment $

Patient's relationship to subscriber

Name of secondary insurance (if applicable)

Subscriber's name

Group no

Policy no

Registration In Case Of Emergency

Name of local friend or relatie (not living at same address)

Relationship to patient

Home phone no

Work phone no

The abose information is true to the best of my knowledge I authorize my insurance benefits be paid directly to the physician I understand that i am financially responsible for any balance I also authorize CARING HANDS MEDICAL CLINIC, LLC or insurance company to release any information required to process my claims.

Patient/Guadian signature

Date

Please list any PREVIOUS and CURRENT medical problems

Please list all past SURGERIES

Please list all CURRENT MEDICATIONS including over the counter medications.

Please list all FOOD and DRUG allergies

Please list your FAMILY MEDICAL HISTORY

Fill this part by replacing the dashes with your answer. where there is Y_N choose your answer and delete the other one. Diabetes, hypertension, cholesterol, cancer, asthma, osteoporosis, coronary artery disease, bleeding disorders, thyroid disorder, depression, substance abuse, mental illness

Father’s health status

Mother’s health status

Our office will file claims with your insurance for all services rendered, to BOTH AND SECONDARY insurance carriers. PLEASE REMEMBER THAT YOU ARE RESPONSIBLE FOR ALL DEDUCTIBLE, CO-PAY AND NON- COVERED SERVICE AMOUNTS

I authorize the release of any medical information necessary to process my claim. Initials

I authorize payment of medical and surgical benefits to Caring Hands Medical Clinic, LLC. Initials

I hereby assign to Elizabeth Ndika, FNP-C any insurance or other third-party benefits available for health care services provided to me. I understand that Elizabeth Ndika, FNP-C has the right to refuse or accept assignment of such benefits.

Patient/Guadian signature

Date

I (or my legal guardian or parent) authorize Elizabeth Ndika, FNP-C to provide medical care reasonable to today’s standards.

Patient/Guadian signature

Date

I understand that as part of my healthcare this organization originates and maintains health records describing my health history, symptoms, examinations, test results, diagnosis, treatment and any plans for future care or treatment. I understand that I have the right to object to the use of my health for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or healthcare operations and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already take action in reliance thereon.

Print name

Patient/Guadian signature

Date