<p> NORTHEAST OHIO MEDICAL ASSOCIATES, LLC PATIENT REGISTRATION FORM PATIENT INFORMATION (Please write information about the patient here)</p><p>First Name: ______MI: ______Last Name: ______Sex: M ____ F____</p><p>By what name would you like to be addressed? ______</p><p>Address: ______City: ______State: ______Zip: ______</p><p>Home Phone #: ______Cell Phone #: ______Work Phone# ______</p><p>Social Security#:______Employer______</p><p>Date of Birth: _____/_____/_____ Age: ______Marital Status: Single Married Widowed Divorced</p><p>Race: _____Asian _____African American/Black _____Caucasian _____Hispanic _____American Indian or Alaskan Native _____Asian or Pacific Islander _____Native Hawaiian _____More than one race _____Other </p><p>Ethnicity: _____Hispanic/Latino _____Not Hispanic/Not Latino _____Filipino </p><p>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.</p><p>Patient Pharmacy & Address: ______</p><p>Patient Email Address:______Primary Care Physician: ______</p><p>Emergency Contact: ______Emergency Contact Phone #: ______</p><p>INSURANCE INFORMATION (Please write information about the patient’s insurance here)</p><p>PRIMARY Insurance Company: ______</p><p>Policy Holder’s Name: ______Date of Birth: _____/_____/_____ SS#: ______</p><p>SECONDARY Insurance Company: ______</p><p>Policy Holder’s Name: ______Date of Birth: _____/_____/______SS#: ______</p><p>WORKERS COMP INJURY RELATED VISIT: (ONLY if the reason for your visit is related to an injury/claim)</p><p>Claim #: ______Date of injury______REFERRAL SOURCE:  Friend/Relative  Web Search (Google, Yahoo, etc)  online yellow pages  Phone Book  Insurance </p><p> Doctor (name of doctor): ______ Other: ______</p><p>PLEASE READ AND SIGN BELOW: </p><p>(I) Direct Payment Request and Authorization to Release Medical Information</p><p>“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.”</p><p>Patient Signature: ______Date: ______-Page 1 of 2 -</p>