PATIENT REGISTRATION

PATIENT NAME

LAST: *

MIDDLE:

FIRST:

SSN: *

DOB:

HOME ADDRESS:

CITY:

STATE:

ZIP:

PHONE:

SEX:

MALE

FEMALE

DRIVER’S LICENSE ID:

EMAIL:

MAIDEN NAME::

REFERRING MD::

MARITAL STATUS:: *

MARRIED

SINGLE

DIVORCED

WIDOWED

EMPLOYER NAME:

PHONE:

EMPLOYER ADDRESS:

SPOUSE / PARENT NAME:

SSN:

SPOUSE / PARENT ADDRESS:

DOB:

CITY:

STATE:

ZIP:

PHONE:

SPOUSE / PARENT EMPLOYER:

PHONE:

EMPLOYER ADDRESS:

NAME OF PERSON TO CONTACT IN CASE OF EMERGENCY:

PHONE:

NAME, ADDRESS & TELEPHONE OF CLOSEST RELATIVE:

INSURANCE INFORMATION

PRIMARY INSURANCE:

ID#:

GROUP#:

SECONDARY INSURANCE:

ID#:

GROUP#:

AUTHORIZATION TO RELEASE INFORMATION AND ASSIGNMENT OF BENEFITS TO AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO ACCESS THIS CLAIM. I PERMIT A COPY OF THIS AUTHORIZATION TO BE USED IN PLACE OF THE ORIGINAL. THIS AUTHORIZATION MAY BE REVOKED BY EITHER OR MY INSURANCE COMPANY AT ANY TIME IN WRITING.

SIGNATURE:

DATE:

I HEREBY AUTHORIZE KALI S. ESWARAN M.D. INC TO APPLY FOR BENEFITS ON MY BEHALF FOR SERVICES RENDERED BY HIM. I REQUEST THAT PAYMENT FROM MY INSURANCE BE MADE DIRECTLY TO KALI S. ESWARAN M.D. INC. I REALIZE THAT THIS MAY NOT PRESENT THE FULL PAYMENT FOR SERVICES RENDERED AND I WILL BE RESPONSIBLEFOR BALANCE DUE. I AGREE TO PAY 1.5% INTEREST PER MONTH FOR BALANCE OVER 60 DAYS FROM THE DATE OF SERVICE.

SIGNATURE:

DATE: