Patient Registration | Suburban Gynecology

Contact Information
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone
Work Phone
Email
Next | Personal Information

Personal Information
Date Of Birth
Date Format: MM slash DD slash YYYY
Social Security Number
Gender
Marital Status
Race
*This question is required for Meaningful Use/Affordable Care Act
Ethnicity
*This question is required for Meaningful Use/Affordable Care Act
Next | Spouse Information
Next | Emergency Contact

Spouse Information
Name of Spouse
First Last
Cell Phone
Email
Next | Emergency Contact

Emergency Contact
Emergency Contact Name
First Last
Relationship
Home Phone
Cell Phone
Email
Emergency Contact Address
Street Address Address Line 2 City State ZIP Code
Next | Insurance Information

Insurance Information
Insurance Company
Policy Number
Group/ID Number
Policy Holder Name
First Last
Date Of Birth
Date Format: MM slash DD slash YYYY
Social Security Number
Relationship To Patient
Do you have a secondary insurance carrier/provider?
- Yes
- No
Next | Secondary Insurance
Next | Physician Information/Pharmacy

Secondary Insurance
Insurance Company
Policy Number
Group/ID Number
Policy Holder Name
First Last
Date Of Birth
Date Format: MM slash DD slash YYYY
Social Security Number
Relationship To Patient
Next | Physician Information/Pharmacy

Physician Information/Pharmacy
Referring Physician
First Last
Office Number
Primary Care Physician
First Last
Office Number
Pharmacy Information
Pharmacy Name
Pharmacy Phone Number
Pharmacy Address
Street Address City State ZIP Code
Cross Street
Next | HIPAA and Patient Policy Form

HIPAA and Patient Policy Form
Initial each section and digitally sign at the end of the form.
HIPAA PRIVACY NOTICE AND OTHER PROVISIONS
I hereby acknowledge that I have been offered a copy of the Notice of Privacy Practices from the office staff and have been informed of my additional rights under HIPAA.
Please Initial
NO SHOW POLICY
I hereby acknowledge that I have been informed of the "NO SHOW" policy practices of the office and that I must cancel all appointments at least 24 hours in advance to avoid a $40.00 cancellation fee.
Please Initial
CONSENT TO TREAT
I hereby authorize and consent to the performance of examinations, diagnostic procedures, injections, and treatments, which my physician and I agree are necessary. I understand that no guarantee has been made as to the results of the care, treatment, and/or medications given to me. T his consent shall remain in effect until I choose to revoke it in writing.
Please Initial
AUTHORIZATION TO DISCUSS MY MEDICAL INFORMATION AND ACCOUNT
My medical condition, information and account may be discussed with the following persons:
Name
First Last
Relationship
Name
First Last
Relationship
Please Initial
RELEASE OF INFORMATION AND ASSIGNMENT OF BENEFITS
I understand that Suburban Gynecology, LLC will submit claims on my behalf to my insurance company; I hereby authorize Suburban Gynecology, LLC to furnish information to my insurance carrier concerning all conditions including those that may reference drug abuse, alcohol abuse, mental illness, or HIV status. I hereby assign to Suburban Gynecology, LLC payments made by my insurance carrier until such time as I revoke this in writing.
Please Initial
PATIENT FINANCIAL RESPOSIBILITY
I understand that as a courtesy to me, Suburban Gynecology, LLC will submit the charges for my visit to my primary and secondary insurance carriers. If there are any questions regarding coverage, benefits, or payments for services provided, I understand that it is my responsibility to resolve them. I also understand that I am financially responsible for all charges whether or not they are covered by my insurance carrier.
Please Initial
Next | Communication Agreement

Digital Signature
My typing my name in the box below indicates my knowledge of and agreement with all of the above. Furthermore, I understand and agree that my Consents/assignments remain in effect until I choose to revoke them in writing.
Typed Signature of patient or authorized representitive
Date Of Birth
Date Format: MM slash DD slash YYYY
Todays Date
Date Format: MM slash DD slash YYYY
If signed above by representative, what is the relationship of signee to patient
Name of patient if different from above
First Last

Register Online

Online Patient Registration Form

Contact Information

Next | Personal Information

Personal Information

Next | Spouse Information

Next | Emergency Contact

Spouse Information

Next | Emergency Contact

Emergency Contact

Next | Insurance Information

Insurance Information

Next | Secondary Insurance

Next | Physician Information/Pharmacy

Secondary Insurance

Next | Physician Information/Pharmacy

Physician Information/Pharmacy

Pharmacy Information

Next | HIPAA and Patient Policy Form

HIPAA and Patient Policy Form

Next | Communication Agreement

Communication Agreement

Next | Digital Signature

Digital Signature