Patient Registration Form

Doctor*
- Dr. Beer
- Dr. Bourne
- Dr. Butler
- Dr. Chafik
- Dr. FitzPatrick
- Dr. Jain
- Dr. Siegel
Patient Information
Last Name*
First Name*
Middle Name
Mailing Address*
City*
State*
ZIP*
Physical Address (if different)
Home Phone
Work Phone
Cell Phone
Date of Birth*
Age*
Social Security Number
Marital Status*
- Single
- Married
- Divorced
- Widowed
- Life Partner
Spouse's Name
Employer
Occupation
Patient E-mail
Preferred Pharmacy/Location
Is this related to a work injury?*
- No
- Yes
IF YES - PLEASE FILL OUT THE WORKERS' COMP INFORMATION BELOW
Guarantor Information
Relationship to Patient*
- Self / Same
- Spouse
- Parent / Guardian
Last Name*
First Name*
Middle Name
Mailing Address*
City*
State*
ZIP*
Home Phone
Work Phone
Cell Phone
Date of Birth*
Age*
Social Security Number
Emergency Contact Information
Relationship*
Last Name*
First Name*
Home Phone
Work Phone
Cell Phone
Race / Ethnicity
- Caucasian
- African American
- Asian
- Hispanic
- Native American
- Other Race
If Other, please specify:
Ethnicity: Do you identify with an Ethnic Origin? If Yes, please specify:
Insurance Information
- Self Pay
- Insurance
- Workers' Comp
- Auto/Homeowner's Liability
- Insurance Other
If Other, please specify:
*Southwest Shoulder, Elbow and Hand does not bill third-party liability.
Primary Insurance
ID#
Group#
Type
- HMO
- PPO
- POS
Claims Address
City
State
ZIP
Subscriber Name
Relationship to Patient
Date of Birth
Social Security Number
Secondary Insurance
ID#
Group#
Type
- HMO
- PPO
- POS
Claims Address
City
State
ZIP
Subscriber Name
Relationship to Patient
Date of Birth
Social Security Number
Workers' Comp Information
Employer at time of injury
Date of Injury
MM slash DD slash YYYY
Insurance Carrier
Claims Address
City
State
ZIP
Adjuster's Name
Adjuster Phone
Claim #
Privacy Policy

Southwest Shoulder, Elbow & Hand Center, P.C. and each member of our staff strongly believe in protecting the confidentiality and security of information we collect about you. Your personal information will only be used to communicate with your other physician(s) or to help procure appropriate payment from your insurance company. By signing below, I acknowledge a complete Notice of Privacy Policy has been made available to me.

I acknowledge it is my responsibility to notify Southwest Shoulder, Elbow & Hand Center, P.C. of changes to any of my insurance(s) including additions, terminations and/or enrollment at the time the event occurs. Otherwise, I understand I may be responsible for any charges that occurred during this time.

ALL INFORMATION THAT I HAVE PROVIDED IS CURRENT AND ACCURATE TO THE BEST OF MY KNOWLEDGE
Privacy Agreement*
I agree to the Privacy Policy.
Full Name*
Date*
MM slash DD slash YYYY

Southwest Shoulder Elbow & Hand Center PC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

Privacy Policy

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Patient Registration Form

Patient Registration Form

Patient Information

Guarantor Information

Emergency Contact Information

Race / Ethnicity

Insurance Information

Workers' Comp Information

Privacy Policy