Patient Registration

Information

Insurance cards copied

Date:

8/26/2014

Account#:

Please PRINT AND complete ALL sections below!

YES

Is your condition a result of a work injury

NO
PATIENTS PERSONAL INFORMATION
Name:
Mullins

An auto accident? YES NO

Single Married Divorced Widowed

Nicodemus

Last Name

Street Address:
Home Phone:
Date of Birth:

Mo.

Day

Date of injury:

8/26/2014

Sex: Male Female

C

First Name

Initial

1564 Allgood Way

Apt #
City:
Las Vega
( 777) 777-9311
Work Phone: ( 777) 645-1504
Social Security #:
11/ 07 /1975 Drivers License: (State & Number)
10462578

Employer/Name of School:
Spouses Name: Mullins

Insurance #:
Co-Payment: $

State:

NV
104-

Zip:
16

15806
-2384

Year

Full Time Part Time

Spouses Work phone: ( 777) 463-9519

Mullins Builders
Charlene
Last Name

How do you wish to be addressed?

First Name

Initial

Nick

Social Security #:

PATIENTS/RESPONSIBLE PARTY INFORMATION

Responsible party:
Relationship to Patient: Self Spouse
Other
Responsible Partys home phone: ( )
Address:
Apt#
Employers Name:
Address:
Apt#
Your Occupation:
Spouses Employer Name:
Address:

104-

Date of Birth:
Social Security #:
Work Phone:

/
-

State:

Zip:

State:

Zip:

()

City:

City:

/
-

-2384

()

City:
Phone No:

16

Spouses Work phone:

State:

()
Zip:

PATIENTS INSURANCE INFORMATION

Please present insurance cards to receptionist.
PRIMARY insurance companys
Blue Cross Blue Shield
name:
Insurance address:
1755 Insured Dr.
City: Sumter
State: SC Zip: 34856
Name of insured:
Nicodemus Mullins
Date of Birth: 11/07/1975
Relationship to insured: self
Insurance ID number: 123456466
Group number:
XY5463
Check if appropriate:

Medigap policy
coverage

Retiree

PATIENTS REFERRAL INFORMATION

Referred by:
Dr. FeelGood
Name(s) of other physician(s) who care for you:

If referred by a friend, may we thank her/him?

YES NO

EMERGENCY CONTACT
Name of person not living with you:
Charlene Mullins
Address:
1564 Allgood Way
Phone number (home):
(777)463-9519

City: Las Vegas

Phone number (work)

Relationship: wife
State: NV
()

Zip:

15806

Assignment of Benefits Financial Agreement

I hereby give lifetime authorization for payment of insurance benefits to be made directly to
, and
any assisting physicians, for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by
insurance. In the event of default, I agree to pay all costs of collection, and reasonable attorneys fees. I hereby authorize this healthcare
provider to release all information necessary to secure the payment of benefits.
I further agree that a photocopy of this agreement shall be as valid as the original.

Date:
8/26/2014
Method of payment:

Nicodemus C. Mullins
Your Signature:
Cash Check Credit Card
PATIENT REGISTRATION