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

Primary Care Physician

This is a required question

Patient's Last Name, Middle, First

This is a required question

Mr.
Miss
Mrs.
Ms.

This is a required question

Patient's Date of Birth

Sex

Male
Female
Other

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Patient's Address

#, Street, City, Zip, Country

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Social Security Number

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Home Phone Number

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Cell Phone Number

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Business Phone Number

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Occupation

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Employer

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Name of Primary Insurance

Please give Insurance Card to Receptionist upon arriving

This is a required question

Policy Holder's Name

This is a required question

Policy Holder's SSN

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Birth Date

Group Number

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Policy Number

This is a required question

Co-Payment Amount $

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Patient's Relationship to Policy Holder

Self
Spouse
Child
Other:

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Name of Secondary Insurance

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Policy Holder's Name

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Group Number

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Policy Number

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Patient's Relationship to Policy Holder

Self
Spouse
Child
Other:

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Medical Doctor's Name/ Address

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Current foot complaints / symptoms

This is a required question

IN CASE OF EMERGENCY: Local friend or relative's name

Not living at same address

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Relationship to Patient

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Home phone number

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Cell phone number

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