PATIENT REGISTRATION FORM

Tsung & Virmani Medical Group, Inc.

1900 El Camino Real, Suite #119

Menlo Park, CA 94027

 

NAME: ____________________________________ DATE OF BIRTH: ________________

 

ADDRESS: __________________________________________________________________

 

CITY: ______________________________________STATE:  ___________ZIP:__________

 

PHONE (home):______________________________PHONE (cell):_____________________

 

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

 

Married □     Divorced □       Widowed/er □   Single □    Partner □

 

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

 

NAME OF PRIMARY INSURANCE COMPANY:  ___________________________________

 

ID/Policy #:  _________________________________ Group #________________________

 

RxBIN:________________   RxPCN:_______________    RxGroup:_________________

 

INSURED PERSON ______________________________________

     

RELATIONSHIP TO PATIENT ________________ DATE OF BIRTH: ________________

 

***Please provide copies of back and front of all insurance cards***

 

NAME OF SECONDARY INSURANCE COMPANY (if any): __________________________

 

ID/Policy #:  _________________________________ Group #________________________

 

RxBIN:________________   RxPCN:_______________    RxGroup:_________________

 

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________________________