C104 Pt Registration 05-20-10.xlsm
Transcripción
C104 Pt Registration 05-20-10.xlsm
Patient Registration Form UNM MEDICAL GROUP, INC. Patient Registration Form Center for Development and Disability for Life 2300Center Menaul Blvd NE 4700 Jefferson NE, Suite 100 Albuquerque, 87107 Albuquerque,New New Mexico, Mexico, 87109 Phone: (505) 272-3000 Fax: (505) 272-2014 PATIENT INFORMATION Patient's Name (Last, First, MI):_________________________________________________________DOB:__________________ Address:____________________________________________________ 3KRQHBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB City:________________________________ State: Patient's SSN:_________________________________ Sex: Patient's Employment Status:_____________________ Zip: M F Occupation:_____________________________________________ Employer Name:__________________________________________________ Employer Phone: Employer Address:________________________________________(PDLO$GGUHVV______________________________ PARENT / GUARDIAN (IF PATIENT IS A MINOR) Name:______________________________________________________ Relationship:______________________________ Address:_________________________________________________________________________________________________ City:________________________________ State: Zip: Phone: NEXT OF KIN / EMERGENCY CONTACT INFORMATION Next of Kin:__________________________________________________ Relationship:______________________________ Address:_________________________________________________________________________________________________ City:________________________________ State: Zip: Phone: REFERRING PROVIDER Provider/Agency Name:_______________________________________ Phone/Fax:_______________________________ Address:_________________________________________________________________________________________________ INSURANCE INFORMATION Is patient covered under Medicare/Medicaid? (please circle )Yes / No If covered under Medicaid, which salud? (please circle) lease ci Medicare/Medicaid #:_____________________________ Molina / BCBS / Lovelace / Presbyterian Is patient covered under Insurance? (please circle) Yes / No (Please circle) yes, please provide the following: If yes, please provide theIffollowing: Policy holder's Name: _____________________________________________ Policy holder's DOB:_________________________ Policy holder's SSN:_________________________________ Relationship to Patient:_________________________________ Insurance Company:__________________________________________ Phone:___________________________________ Address:_________________________________________________________________________________________________ Group #:___________________ Policy #:_________________________ Policy holder's Employer:___________________________________________ Authorization #:____________________________ Occupation:_______________________________ Employer Address:_________________________________________________________________________________________ City:________________________________ State:________ Zip:__________Telephone:________________________________ Authorization I hereby authorize CDD or UNM Medical Group, Inc. to release any information acquired in the course of my evaluation to the insurance company. I understand I have the right to examine and copy the information disclosed. I authorize payment directly to CDD or UNM Medical Group, Inc. for the medical benefits. Signature:________________________________________________________________________ Date:_________________ CDD 06/04/12 Patient Registration Form UNM MEDICAL GROUP, INC. Registration Form CenterPatient for Development and Disability forBlvd LifeNE 2300Center Menaul 4700 Jefferson NE, Suite 100 Albuquerque, New Mexico, 87107 Albuquerque, New Mexico, 87109 272-3000 Fax: (505) 272-2014 Phone: (505) 505-925-7464 505-925-4539 Información de Paciente: Nombre de Paciente:_________________________________________ Fecha de Nacimiento:_____________________ Direccion:___________________________________________________ Preferencia Religiosa:__________________________ Ciudad:_____________________________ Estado: Código Postal:__________ Telefono: Seguro Social de Paciente:____________________________ Sexo: M F Estado de empleo del paciente:________________________ Ocupacion:____________________________________________ Patrón de Paciente:________________________________________________ Telefono del Patrón: Direccion del Patrón:_______________________________________________________________________________________ PADRE / GUARDA (Si El Paciente es un Menor de Edad) Nombre de Padre/Guarda:___________________________________________ Relación:________________________________ Direccion: __________________________________________________________________________________________________ Ciudad:_____________________________ Estado:_______ Código Postal:__________ Telefono: Información de Contacto para Emergencia/Familia: Nombre:________________________________________________________ Relación:________________________________ Direccion: ________________________________________________________________________________________________ Ciudad:_____________________________ Estado:_______ Código Postal:__________ Telefono: N REFERRING PROVIDER Nombre del proveedor / agencia:________________________________ Telefono:_________________________________ Direccion: ________________________________________________________________________________________________ Información de Aseguranza: ¿Tiene el paciente Medicare y/o Medicaid? SRUIDYRUFtUFXOR Sí / No Si está cubierto por Medicare, que Salud? por favor círculo Esta asegurado(a)? SRUIDYRUFtUFXOR Sí / No Número de Medicare/Medicaid: _______________________ Molina / BCBS / Lovelace / Presbyterian Por favor proveer la siguiente información: Nombre del Asegurado(a):______________________________________ Fecha de Nacimiento:_______________________ Número de Social Asegurado(a):_________________________________ Relación del Paciente:_______________________ Nombre de Aseguranza:_______________________________________ Número de Telefono:_______________________ Direccion:________________________________________________________________________________________________ Grupo #:__________________ Poliza de Seguro #:_____________________ Autorización#:____________________________ Nombre de Patrón:____________________________________________ OccUNMMGcion:_________________________ Dirección del Patrón:_______________________________________________________________________________________ Ciudad:_____________________________ Estado:_______ Código Postal:__________ Telefono del Patron:______________ Autorización Estoy autorizando a CDD o University Physicians Associates (UNMMG) para divulgar la información obtenida en el transcurso de mi evaluación necesaria para asuntos de aseguranza. Comprendo que también tengo derecho a examinar y obtener una copia de la información divulgada. Firma:______________________________________________________________ CDD 06/04/12 Fecha:__________________________
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C104 Pt Registration 05-20-10.xlsm
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