Cardiac Center of Texas, P.A.
REGISTRATION FORM
Today's Date:7/29/2010PCP :
PATIENT INFORMATION
Patient's Last name    First   Middle  
Mr. Miss. Mrs. Ms.
Marital Status Single Married Divorced Separated Widow
Is this your legal name? Yes No
If not, what is your legal name?
(Former Name)
Birth Date
Age
Sex Male Female
Home Phone No.
Mobile No.
Email Address
Social Security No   
Street Address / PO Box
City
State
Zipcode
Occupation
Employer
Employer Phone No.
   
Choose Clinic Because /Referred to Clinic by (please check one box) Dr.  Hospital
 Insurance Plan Family Friend Close to Home/Work Yellow Pages Other 
Other Family member seen here
 
INSURANCE INFORMATION (PLEASE GIVE YOUR INSURANCE CARD TO THE RECEPTIONIST)
Person Responsible for Bill
Birth Date
Address (if different)
Home Phone No.
Occupation
Employer
Employer Address
Employer Phone No.
Is this patient covered by insurance? Yes No
   
Please indicate primary insurance Medicare  Medicaid Aetna BCBS Cigna
 Choice Care(Humana) First Health PacifiCare United Healthcare Secure Horizons
Other  
Subscriber Name's
Subscriber Social Security's #   
Birth Date
Group #
Policy #
Co-payment
Patient's Relationship to Subscriber  SelfSpouseChild Other  
Name of the Secondary Insurance (if applicable)
Subscriber's Name
Policy #
Group #
Subscriber Social security#   
Birth Date
 
INCASE OF EMERGENCY
Name of the Local Friend or Relative (Not Living in the same Address )
Relationship to Patients
Home Phone No.
Work Phone No.
The above information is true to the best of my knowledge. This office will ask to verify all information above at each appointment.This form will be updated annually.Sooner if any information contained here is no longer valid.
I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Cardiac Center of Texas,P.A or insurance company to release any information required to process my claims.
 
X 
 
PATIENT/GUARDIAN SIGNATURE DATE
 
 
 
 
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