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    Apgpatient Registration Form

    Uploaded by

    samnanuel
    patient

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Apgpatient Registration Form

    Uploaded by

    samnanuel
    1 views4 pages
    patient

    Original Title

    apgpatient_registration_form

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

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    patient

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    1 views4 pages

    Apgpatient Registration Form

    Uploaded by

    samnanuel
    patient

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    Patient Registration Form

    Patient Information:

    Primary Care Physician:___________________________

    Reason for NO Primary Care Physician: ________________________________________________

    Social Security # / /

    Last Name: First Name: ___________ Middle Name: _ _______________ Suffix_____

    Preferred First Name: ___________________

    Sex Male / Female / Transgender Birth Sex: Male/Female Date of Birth: / /

    Preferred Language: _____________________

    Marital Status:
    Divorced /Legally Separated /Life Partner /Married /Civil Union /Registered Domestic Partner /Single /Widowed
    Race: __________________ Ethnicities: _____________________

    Home Address

    Address Line 1 __________________________________________________________________________

    Address Line 2 __________________________________________________________________________

    Country____________________ Zip ___________City _________________State ____

    Circle Preferred Phone Type: Alternate Phone / Home Phone / Mobile Phone / No Phone / Work Phone
    Home # ( ) - ____Cell # ( ) - ____Work# ( ) - ____ Work Ext_______ __

    Alternate # ( ) - _____

    Home E-mail Address: _____________________________________________

    1
    Do you wish to be enrolled into the Healthe Life Portal: Yes/No

    If yes please circle a challenge question.

    Challenge Question: Last four Digits of your SSN / Year you got married / Year you graduated high school / Year
    your father graduated high school /Year your father was born / Year your mother graduated high school / Year your
    mother was born / Your postal code

    Challenge Answer: _________________________

    Are you an Emancipated Minor Yes / No

    Related persons:

    Role: Contact /Guardian /Next of Kin /Power of Attorney

    Last Name: First Name: ___________ Middle Name: _ _______________ Suffix_____

    Home # ( ) - ____Cell # ( ) - ____Work# ( ) - ____ Work Ext_______ __

    Alternate # ( ) - _____ Patient Relationship to Related Person: ____________________________

    Guarantor:

    Self: Yes / No

    Please fill out below if anything other than self:

    Guarantor Legal Name:

    Last Name: First Name: ___________ Middle Name: _ _______________ Suffix_____

    Preferred First Name: ___________________

    Sex: Male / Female/ Transgender Birth Sex: Male/Female Date of Birth: / /

    Social Security # / /

    Home # ( ) - ____Cell # ( ) - ____Work# ( ) - ____ Work Ext_______ __

    Alternate # ( ) - _____

    Address Line 1__________________________________________________________________________

    Address Line 2__________________________________________________________________________

    2
    Country________________________________ Zip ___________City _________State ____

    Insurance Information:

    Name of PRIMARY Insurance

    If Medicare: Is the patient a Veteran? Y / N Are you currently employed? Y / N

    Do you have a Federal Black Lung Card? Y / N Is your spouse/partner currently employed Y / N

    Policy / Subscriber # Group #

    How is the Subscriber related to you? Self / Spouse / Child / Guardian

    Policyholder / Subscriber Information:

    First Name Middle Initial Last Name

    Social Security # / / Date of Birth: / / Age: Sex M / F / T

    Address

    City State Zip

    Home Phone # ( ) Cell Phone # ( )

    Subscriber’s Employer

    Work # ( ) Employer’s Address

    City State Zip:

    Name of SECONDARY Insurance Company

    Policy / Subscriber # Group #

    How is the Subscriber related to you? Self / Spouse / Child / Guardian/ Partner

    Policyholder / Subscriber Information:

    First Name Middle Initial Last Name

    Social Security # / / Date of Birth: / / Age: Sex M / F / T

    Address City St Zip

    Home Phone # ( ) Cell Phone # ( )

    Subscriber’s Employer Work #

    Employer’s Address

    3
    City State Zip

    Employment Status (circle one) Full-time / Part-time / Self Employed / Retired / Military

    Patient’s Occupation Work #

    Employer Address

    City State Zip

    Is it okay to leave messages at: Work? Y / N If Student, indicate School


    Student Status FT/ PT

    Pharmacy Information:

    Retail Pharmacy Name:

    Phone # ( ) Fax # ( ) Location

    ID#

    Mail Order Pharmacy:

    Phone # ( ) Fax # ( )

    ID #

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