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________________________