REGISTRATION FORM

Today's Date: Your Primary Care Doctor:

PATIENT INFORMATION

Patient's Last Name First Middle Mr. Mrs. Miss Ms. Marital Status (Circle One) Single Mar Div Sep Wid

Is this your legal name? If not, what is your legal name? (Former Name) Birth Date Age Sex Yes   No M   F

Street Address City State ZIP Code Social Security Home Phone No

P.O. Box City State ZIP Code

Occupation Employer Employer Phone No.

Chose Office Because / Referred to Office by (Please check one box) Dr. Insurance Plan Hospital Home Phone No Family Friend Close to Home/Work Yellow Pages Other

Other Family Members Seen Here

INSURANCE INFORMATION (PLEASE GIVE YOUR INSURANCE CARD TO THE RECEPTIONIST)

Person Responsible for Bill Birth Date Address (if different) Home Phone No. Is this person a patient here? Yes   No

Occupation Employer Employer Address Employer Phone No.

Is this patient covered by insurance? Yes   No   Please indicate primary insurance Medicare Aetna Oxford United HealthCare Horizon CIGNA AmeriHealth HealthNet Welfare Other:

Subscriber's Name Subscriber's S.S. # Birth Date Group# Policy# Co-Payment $ Patient's Relationship to Subscriber Self Spouse Child Other:

Name of Secondary Insurance (if applicable) Subscriber's Name Group# Policy# Patient's Relationship to Subscriber Self Spouse Child Other:

Name of Local Friend or Relative (not living at same address) Relationship to Patient Home Phone No. Work Phone No. The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Advanced Neurology Center LLC or insurance company to release any information required to process my claims. PATIENT/GUARDIAN SIGNATURE DATE

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