PATIENT REGISTRATION FORM

Tsung & Virmani Medical Group, Inc.

1900 El Camino Real, Suite #119

Menlo Park, CA 94027

 

NAME: ____________________________________ DATE OF BIRTH:________________

 

ADDRESS: _________________________________CITY:_______________  ZIP:_______

 

PHONE (home):______________________________PHONE (cell):___________________

 

Preferred phone (circle one):  Cell    Home                   Referred by: _____________________

 

EMPLOYER:  _______________________________ PHONE: _______________________

 

EMPLOYER ADDRESS:_____________________________________________________

 

Marital status:       Married □        Divorced □      Widowed □     Single □           Partner □

 

Do you have Medicare?    Yes       No                         Do you have Medi-Cal?          Yes      No

 

INSURANCE COMPANY – PRIMARY:  _______________________________________

 

ID/Policy #:  _________________________________ Group #________________________

 

INSURED PERSON __________________________

     

RELATIONSHIP TO PATIENT  ________________ DATE OF BIRTH:________________

      

      INSURED PERSON’S EMPLOYER:  ______________________PHONE: ______________

 

      INSURED PERSON’S EMPLOYER’S ADDRESS:_________________________________

 

INSURANCE COMPANY – SECONDARY (if any): ______________________________

 

ID/Policy #:  _________________________________ Group #_________________________

 

INSURED PERSON __________________________

     

RELATIONSHIP TO PATIENT  ________________ DATE OF BIRTH:_________________

 

EMERGENCY CONTACT NAME:   _________________________________________

 

EMERGENCY CONTACT PHONE#: _________________________________________

 

I authorize Tsung & Virmani Medical Group, Inc. to release any medical information necessary to process insurance claims.  I acknowledge that I am financially responsible for services received, regardless if these services are covered by my health plan.

     

Signature  ___________________________________  Date________________________