UPPER BUCKS ORTHOPAEDIC ASSOCIATION

PATIENT REGISTRATION FORM

* Indicates required field

DATE:

*NAME:

*STREET ADDRESS: *CITY:

*STATE: *ZIP CODE:

TELEPHONE NUMBER: *(Home) (Work) EMAIL:

*BIRTHDATE      AGE: SEX: Male Female SS#

MARITAL STATUS: Single Married Divorced Widowed

EMPLOYER (Parent’s employer if patient is a minor)

STREET ADDRESS: CITY:

STATE: ZIP CODE:

CONTACT IN AN EMERGENCY: TELEPHONE NUMBER:

*PREFERRED PHARMACY: *ADDRESS:

REFERRING PHYSICIAN:

FAMILY PHYSICIAN: TELEPHONE NUMBER:

STREET ADDRESS: CITY:

STATE: ZIP CODE:

RESPONSIBLE PARTY:

NAME:

STREET ADDRESS: CITY:

STATE: ZIP CODE:    TELEPHONE NUMBER:

BIRTHDATE      SS#

PRIMARY INSURANCE: Medical Medicare MA Auto* Workers’ Compensation*

COMPANY:

STREET ADDRESS: CITY:

STATE: ZIP CODE:

GROUP #: POLICY #:

SUBSCRIBER: DOB: SS#:

STREET ADDRESS: CITY:

STATE: ZIP CODE:

INSURED EMPLOYER:

STREET ADDRESS: CITY:

STATE: ZIP CODE:

* ADJUSTER NAME: TELEPHONE NUMBER:

* CLAIM # * DATE OF INJURY/ACCIDENT:

SECONDARY INSURANCE: Medical Medicare MA

COMPANY:

STREET ADDRESS: CITY:

STATE: ZIP CODE:

GROUP #: POLICY #:

SUBSCRIBER: DOB: SS#:

STREET ADDRESS: CITY:

STATE: ZIP CODE:

ARE YOU TO BE TREATED FOR AN INJURY: Yes No

If yes, please check what type of injury. Auto Work Motorcycle Sports

INFORMATION RELEASE

I authorize the release of any Medical Information necessary to process this claim and request payment of Medical Benefits to the undersigned physician for services rendered.

I authorize all benefit payments be made directly to Upper Bucks Orthopaedic Association. I understand that I am financially responsible for any non-covered services and unpaid balances as well as DEDUCTIBLE and COINSURANCES as determined by MEDICARE/MEDIGAP or other insurance carrier. I am also responsible for any and all collection fees if the account becomes delinquent.

Signature Date