Patient Registration

Evergreen Prosthetics and Orthotics Patient Registration Form

PatientRegistration - Click here for larger version

Patient Name (First, Middle Initial, Last Name): __________________________________________________________________
Address: _______________________________________________________ City/State/Zip: ____________________________
Phone: ____________________________ Cell No: ___________________________ Wk No: ____________________________
Sex:__________ Date of Birth: _______________ SS No: _______________________ Employer: ________________________

Are you diabetic? _______________ Shoe Size:_______________ Height:________________ Weight:________________

Emergency/Alternate Contact(s)
Name, Relationship & Number: _______________________________________________________________________
Primary Care Physician (Name & Phone Number):__________________________________________________________

Referring Physician (Name & Phone Number):_____________________________________________________________________

Insurance Information

Primary Insurance
Carrier Name of Insurance Co.: _________________________________________ ID: __________________________

Group Name/Employer: __________________________________________ Group No.: _________________________

Subscriber Name (if other than patient): _________________________________ Subscriber Date of Birth:_____________

Secondary Insurance
Carrier Name of Insurance Co.: _________________________________________ ID: __________________________

Group Name/Employer: __________________________________________ Group No.: _________________________

Subscriber Name (if other than patient): _________________________________ Subscriber Date of Birth:_____________

Please ONLY complete this section if your injury is related to the following.
Work Injury / Motor Vehicle Accident / Other Liability (Please circle one.)
Carrier Name: _____________________________________ Claim No.: _____________________________________

Date of Injury/Accident: ____________ Adjuster Name & Phone No.: __________________________________________

If work Injury: Employer Name & Phone Number @ Time of Injury: _____________________________________________

If motor vehicle accident: Policy Holder Name & Phone No.: __________________________________________________

Assignment of Benefits & Notice of Financial Responsibility:
I authorize Evergreen Prosthetics & Orthotics, LLC to bill my insurance for payment of services rendered. Any quote of coverage or potential financial responsibility given by an Evergreen employee is not a guarantee and is subject to change and will ultimately be based on the processing by your insurance provider. I agree to provide Evergreen Prosthetics & Orthotics, LLC with my correct billing and contact information or I may be responsible for any balance(s) incurred. I agree that any returned checks will accrue a charge of $25 for each occurrence. I understand that I am ultimately responsible for the balance of my account and agree to pay in a timely manner.

Guardian/Legal Representative Signature: ____________________________________________________________
Relationship to Patient: _____________________________________________________ Date: ________________

Patient Signature: ___________________________________________________¬¬¬______ Date: _______________
Effective 09/01/2010