Northwest Physicians Associates, Pc

NORTHEAST OHIO MEDICAL ASSOCIATES, LLC PATIENT REGISTRATION FORM PATIENT INFORMATION (Please write information about the patient here)

First Name: ______MI: ______Last Name: ______Sex: M ____ F____

By what name would you like to be addressed? ______

Address: ______City: ______State: ______Zip: ______

Home Phone #: ______Cell Phone #: ______Work Phone# ______

Social Security#:______Employer______

Date of Birth: _____/_____/_____ Age: ______Marital Status: Single Married Widowed Divorced

Race: _____Asian _____African American/Black _____Caucasian _____Hispanic _____American Indian or Alaskan Native _____Asian or Pacific Islander _____Native Hawaiian _____More than one race _____Other

Ethnicity: _____Hispanic/Latino _____Not Hispanic/Not Latino _____Filipino

Preferred Language: ______(English, Spanish, French, etc.) Preferred Contact Method: ______(Postal mail, Phone, Secure messaging/Patient Portal) *Note that this may be used for appointment reminders, test results, and other communications from the practice.

Patient Pharmacy & Address: ______

Patient Email Address:______Primary Care Physician: ______

Emergency Contact: ______Emergency Contact Phone #: ______

INSURANCE INFORMATION (Please write information about the patient’s insurance here)

PRIMARY Insurance Company: ______

Policy Holder’s Name: ______Date of Birth: _____/_____/_____ SS#: ______

SECONDARY Insurance Company: ______

Policy Holder’s Name: ______Date of Birth: _____/_____/______SS#: ______

WORKERS COMP INJURY RELATED VISIT: (ONLY if the reason for your visit is related to an injury/claim)

Claim #: ______Date of injury______REFERRAL SOURCE:  Friend/Relative  Web Search (Google, Yahoo, etc)  online yellow pages  Phone Book  Insurance

 Doctor (name of doctor): ______ Other: ______

PLEASE READ AND SIGN BELOW:

(I) Direct Payment Request and Authorization to Release Medical Information

“I request that payment of authorized benefits be made either to me or on my behalf to Northwest Physicians Associates, P.C. for any services furnished to me by that physician or supplier. I authorize any holder of medical information about me to release to my insurance company and its agents any information needed to determine these benefits or the benefits payable for related services.”

Patient Signature: ______Date: ______-Page 1 of 2 -