Patient Registration Form (MOM) - Mind Over Matter Health

Patient Registration Form

Name

DOB

Gender

Pronouns

Race

Ethnicity

S.S

Address

City

State

Zip Code

Home Phone

Cellphone

Preferred Contact Phone

Home

Cell

Day

Emergency Contact

Relationship

Phone#

Primary Insurance

Secondary Insurance

Primary Insurance Phone

Secondary Insurance Phone

Primary Insurance Address

Secondary Insurance Address

Primary Policy #

Secondary Policy #

Primary Group #

Secondary Group #

Primary Policy Holder

Secondary Policy Holder

Primary DOB

Secondary DOB

PCP

PCP Phone and Fax#

Referring Provider

Phone and Fax#

Pharmacy

Phone #

Address

Authorization and Signature on File

I authorize the release of any medical information to my insurer and/or CMS and its agents to process my insurance claims. I authorize payment of benefit directly to Mind Over Matter NP in Psychiatry and Family Health P.C. on my behalf. I agree that this authorization will cover all medical services rendered until such authorization is revoked by me. I agree that a photocopy of this form may be used in lieu of the original. I agree to pay all charges not covered or later to be determined to be ineligible by my insurance carrier(s). These charges include but are not limited to deductibles, coinsurance, and copayments on my insurance policy. If the doctor is not participating with my insurance plan or I have not obtained the proper insurance referrals and authorizations, I am responsible to pay the full bill for all services rendered.

Consent

I agree to receive medical/psychiatric services from Mind Over Matter NP in Psychiatry and Family Health P.C.. I understand that this involves sharing health information between my medical providers within the practice.

Acknowledgement

I acknowledge that this information will not be shared outside of this practice without my consent.

Print Name

Date

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