PATIENT REGISTRATION FORM

Patient’s Name: _______________________________  SSN: ______________________

Address:  ________________________________________________________________

City:____________________________ State: ___________    Zip: ___________________

Home phone: _______________  Age:   _____    D.O.B ______________  Sex:   M  /  F

Please indicate best phone number to be reached at during the day:  (H / C / W):

________________________________________________________________________
If patient is a minor, name of parent or guardian:  __________________________________

Emergency Contact: _________________________ Relationship: __________________

Phone: (work) ______________________________  Home:   _______________________

Referring Physician: ____________________________  Phone: ___________________

Primary Care Physician: _________________________   Phone:  __________________

Problem being seen for: ___________________________________________________

Insurance Information: _______________ ID: ____________________ Group :________

Subscriber: ___________________________  Relationship to patient:  ________________

Subscribers' Date of Birth (mandatory):  _______________________

**Please bring current insurance card to your initial visit**

Is your injury work related?  □ Yes  □ No   Date of injury: __________ □ MVA  □ Work  □ Other

WORKER’S COMPENSATION OR MOTOR VEHICLE INSURANCES

Employer: (if worker's comp) _________________________________________________

Insurance Company: _______________________________________________________

Billing address: ___________________________________________________________

Contact Person:___________________________________________________________

Phone number: ___________________________________________________________

Date of injury / accident: ______________________  State accident occurred in:  ________

How did you find out about Main Line Hand Center? 

□ Doctor Recommendation, Doctor's Name:  _____________________________________
□ Internet    □  Friend/Name __________________________________________________

□ Other, please explain:   ____________________________________________________

Today's Date:  ____________________________
 

----------------------------------------------- OFFICE USE ONLY -----------------------------------------------

Diagnosis:  __________________  DX code:  ____________
 

VERIFIED PRIMARY INSURANCE INFORMATION:

In / out of network:  _________________   Effective Date:  _______________

Deductible:  _________________   Amount Met:  __________________

Co-pay:  ____________________  Co-insurance:  ________________________________

Visit limitation:  per year Y / N   Per condition Y / N: _________________________________

Pre-certification required:  Y / N

WORKER'S COMPENSATION / MVA:

Claim #:  _____________________________  Claim is OPEN / CLOSED 
Does primary insurance accept cross-over claims:   Y /  N