FARIDA BOUNOUA, MD
Patient Registration Form
PATIENT REGISTRATION
Please PRINT:
PATIENT:
BIRTHDATE:
(Last)
(First)
HOME PHONE:
SOCIAL SECURITY #:
SEX: (circle one) MALE FEMALE
STREET / MAILING ADDRESS:
CITY:
STATE:
MARITAL STATUS: (circle one)
SINGLE
AGE:
(Middle)
MARRIED
SEPARATED
ZIP CODE:
DIVORCED
WIDOWED
EMPLOYER:
EMPLOYER ADDRESS:
OCCUPATION:
WORK PHONE:
PRIMARY DOCTOR:
DOCTOR’S PHONE:
REFERRING DOCTOR:
DOCTOR’S PHONE:
SPOUSE/PARENT:
SOCIAL SECURITY #:
(Last)
(First)
WORK PHONE:
EMPLOYER:
OCCUPATION:
(Middle)
EMPLOYER ADDRESS:
PERSON RESPONSIBLE:
RELATIONSHIP TO PATIENT:
EMERGENCY CONTACT:
PHONE:
DATE OF INJURY:
DATE LAST WORKED:
RECENT X-RAYS TAKEN WHEN?
DATE BACK TO WORK:
X-RAYS TAKEN WHERE?
INSURANCE INFORMATION:
Please present your insurance card(s) to the receptionist.
PRIMARY INSURANCE COMPANY:
Mailing Address:
City:
Name of Subscriber:
Policy Number:
ID Number:
State:
Relationship to Patient:
Group Number:
Effective Date:
Zip Code:
SECONDARY INSURANCE COMPANY:
Mailing Address:
City:
Name of Subscriber:
Policy Number:
ID Number:
State:
Relationship to Patient:
Group Number:
Effective Date:
Zip Code:
Payment Policy: Payment is due at the time services are rendered unless other arrangements have been made. Insurance is
considered a method of reimbursing the patient for fees paid to the doctor, and is not a substitute for payment. It is your responsibility to
pay any deductible, co-insurance, or any balance not paid by your insurance. Payment is the sole responsibility of the patient, patient’s
spouse, or parent of a minor. HMO insurance is generally not accepted into this practice. Any HMO care needs prior authorization and it is
the patients responsibility to have these authorizations in place prior to receiving care.
Patient Authorization: I hereby authorize the release of any medical information necessary to process my insurance claim. I hereby
authorize payment of medical benefits to the named provider for services rendered. I also authorize Palmetto Insurance Company to
release information regarding Medicare claims submitted by the named provider.
SIGNED:
DATE:
(Patient or Guardian if Minor)