PATIENT REGISTRATION
DATE
✓ Check all that apply:
PAGE -1-
❑ Friend ❑ Relative ❑ Other__________________________
Allergy &
Asthma Center, P.C.
❑ Relative
❑ Friend
RELEASE OF INFORMATION AND ASSIGNMENT OF BENEFITS
I hereby authorize Allergy & Asthma Center, P.C. and my insurance company to exchange any information which either party may request concerning my claim.
I furthermore assign to Allergy & Asthma Center, P.C. all insurance payments relative to the services performed.
X______________________________________________________________________________________________ __________________________
SIGNATURE OF RESPONSIBLE PARTY DATE SIGNED
HEALTH INSURANCE INFORMATION
PRIMARY INSURANCE INFORMATION
INSURANCE CO. NAME GROUP NO. OR NAME INSURED'S I.D. # /SOC. SEC. # INSURED'S Last / First Name
INSURANCE CO. ADDRESS CITY STATE ZIP INSURED'S D.O.B. INSURANCE CO. PHONE NO.
SECONDARY INSURANCE COMPANY
INSURANCE CO. NAME GROUP NO. OR NAME INSURED'S I.D. # /SOC. SEC. # INSURED'S Last / First Name
INSURANCE CO. ADDRESS CITY STATE ZIP INSURED'S D.O.B. INSURANCE CO. PHONE NO.
❑ NEW PATIENT ❑ UPDATE ❑ PRIVATE INSURANCE ❑ HMO ❑ PPO ❑ MEDICARE ❑ MEDICAID
PATIENT INFORMATION - PLEASE PRINT CLEARLY
PATIENT NAME LAST FIRST MI DATE OF BIRTH SEX SOCIAL SECURITY #
M D Y ❑ M
/ / ❑ F
PHONE MAILING ADDRESS CITY STATE ZIP CODE
( )
MARITAL STATUS SPOUSE NAME PATIENT OCCUPATION
❑ Married ❑ Divorced
❑ Single ❑ Widow/er
EMPLOYER PHONE EMPLOYER NAME & ADDRESS CITY STATE ZIP CODE
( )
IN CASE OF EMERGENCY NOTIFY (Other than responsible party or spouse) RELATIONSHIP PHONE NO.
( )
REFERRAL INFORMATION
REFERRAL SOURCE: ❑ Yellow Pages ❑ Physician ❑ Hospital NAME OF REFERRING FRIEND/RELATIVE PHONE #
NAME OF FAMILY DOCTOR/PRIMARY CARE PHYSICIAN CITY NAME OF REFERRING DOCTOR OR HOSPITAL CITY DATE OF LAST VISIT
M Y
/
OTHER FAMILY MEMBERS SEEN:
RESPONSIBLE PARTY
(If same as patient, leave blank)
RESPONSIBLE PARTY NAME LAST FIRST MI SEX SOCIAL SECURITY # DATE OF BIRTH RELATIONSHIP
❑ Male TO PATIENT: ❑ Parent
❑ Female ❑ Spouse ❑ Other
PHONE STREET ADDRESS CITY STATE ZIP CODE
( )
EMPLOYER PHONE NO. EMPLOYER NAME & ADDRESS OCCUPATION
( )
IF PATIENT IS A STUDENT OR A MINOR, PLEASE GIVE THE FOLLOWING INFORMATION
FATHER'S NAME (If not listed as responsible party) MOTHER'S NAME (If not listed as responsible party)
ADDRESS (If different than patient) ADDRESS (If different than patient)
HOME PHONE WORK PHONE HOME PHONE WORK PHONE
( ) ( ) ( ) ( )
CONSENT FOR TREATMENT
I hereby request and permit the Allergy & Asthma physicians to render to the above-named patient any medical/surgical treatment he/she may require in my absence.
____________________________________________________________________________ _______________________________ ________________
SIGNATURE OF PARENT OR GUARDIAN RELATIONSHIP DATE SIGNED
Eugene - (541) 485-0316 Corvallis - (541) 754-7170
