Patient Registration Form
Manhattan Podiatry Associates, PC
The below 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 Manhattan Podiatry or insurance company to release any information required to process my
claims. I acknowledge that I was provided and read (or had the opportunity to read)and understood The Notice of Privacy Practice
am aware that the following information is available for viewing upon request;
o Information regarding the providers of care in this organization
. A copy of the Patient's Bill of Rights and Responsibilities
. Information regarding the grievance process
. Ownership of Practice
. DNR Policy
. JCAHO lnformation
Today's Date *
MM
/
DD
/
YYYY
Primary Care Physician *
Patient's Last Name, Middle, First *
*
Marital Status
Clear selection
Patient's Date of Birth *
MM
/
DD
/
YYYY
Sex
Clear selection
Patient's Address *
#, Street, City, Zip, Country
Social Security Number
Home Phone Number
Cell Phone Number
Business Phone Number
Occupation
Employer
Referred to Office by *
Name of Primary Insurance *
Please give Insurance Card to Receptionist upon arriving
Policy Holder's Name *
Policy Holder's SSN
Birth Date
MM
/
DD
/
YYYY
Group Number
Policy Number
Co-Payment Amount $
Patient's Relationship to Policy Holder *
Name of Secondary Insurance
Policy Holder's Name
Group Number
Policy Number
Patient's Relationship to Policy Holder
Clear selection
Medical Doctor's Name/ Address *
Current foot complaints / symptoms *
IN CASE OF EMERGENCY: Local friend or relative's name *
Not living at same address
Relationship to Patient *
Home phone number *
Cell phone number *
Submit
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