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
* Required
Today's Date
*
MM
/
DD
/
YYYY
Primary Care Physician
*
Your answer
Patient's Last Name, Middle, First
*
Your answer
*
Mr.
Miss
Mrs.
Ms.
Marital Status
Married
Single
Divorced
Separated
Widowed
Clear selection
Patient's Date of Birth
*
MM
/
DD
/
YYYY
Sex
Male
Female
Other
Clear selection
Patient's Address
*
#, Street, City, Zip, Country
Your answer
Social Security Number
Your answer
Home Phone Number
Your answer
Cell Phone Number
Your answer
Business Phone Number
Your answer
Occupation
Your answer
Employer
Your answer
Referred to Office by
*
Doctor
Insurance
Internet
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Patient/Friend
Other:
Name of Primary Insurance
*
Please give Insurance Card to Receptionist upon arriving
Your answer
Policy Holder's Name
*
Your answer
Policy Holder's SSN
Your answer
Birth Date
MM
/
DD
/
YYYY
Group Number
Your answer
Policy Number
Your answer
Co-Payment Amount $
Your answer
Patient's Relationship to Policy Holder
*
Self
Spouse
Child
Other:
Name of Secondary Insurance
Your answer
Policy Holder's Name
Your answer
Group Number
Your answer
Policy Number
Your answer
Patient's Relationship to Policy Holder
Self
Spouse
Child
Other:
Clear selection
Medical Doctor's Name/ Address
*
Your answer
Current foot complaints / symptoms
*
Your answer
IN CASE OF EMERGENCY: Local friend or relative's name
*
Not living at same address
Your answer
Relationship to Patient
*
Your answer
Home phone number
*
Your answer
Cell phone number
*
Your answer
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