PATIENT REGISTRATION FORM

NAME:

Title                        First                                   Mi                          Last                                   Date____________________________
Address:  _________________________Apt #                 City                                State              Zip____________
Home Phone (      )                           Work Phone (      )                           Ext.            Social Security____________________
Fax #                                              Cell #                                                     E-Mail Address____                                        Marital Status (Circle)____________
Birthdate                                      Age                       Sex (Circle)      M     F                                           Single   Married   Widowed   Divorced____
Spouse's Name                                     Home Phone (      )                                 Work Phone (     )__________________

Patient's Employer                                                                Patient's Occupation ________________________
Address                                                                            City                                        State                     Zip______________________
Local Relative or Friend                                                                                     Phone (      )___________________________
Address                                              Apt #            City                                    State               Zip_______________________
Referred by:
Drug Allergies:
Name of other immediate family members previously seen in our office:
Our computer groups your family as a unit for accounting purposes unless otherwise indicated here:
_______________________________________________________________________________________

Name of Responsible Party if other than patient
Title             First                                M                                                    Last__________________________
Address                                                         Apt #          City                                 State            Zip__________
Home Phone  (      )                            Work Phone (      )                                   Soc Security #______________
Employer                                                    Address                                       City              State        Zip
_______________________________________________________________________________________
Patients participating in HMO or MC Plans must present valid I.D. cards upon check-in.  Co-Payments are due at time of service

Primary Insurance Company                                             Phone  (      )                                 CoPay__________
Please Check One:          Medicare           Medicaid         HMO         PPO      Other______________________
Address                                                                    City                                   State              Zip____________
Name of Policy Holder:                                             Birthdate:                       ID#               Group#__________
Secondary Insurance Company______________________________________________________________
Address                                                                   City                                   State                 Zip
Name of Policy Holder                                            Birthdate:                        ID#           Group#____________

Fees for services are payable at the time service is rendered.  We will be happy to discus fees with you in the office. 
We charge for missed  appointments without 24 hr cancellation. 
Cancellation notice must be made during regular office hours.  It is your  responsibility to be  aware of coverage limits
within your insurance plan.  If you are not satisfied with payment on a claim, contact your insurance company

Authorization to Release Information:  I hereby authorize Urban Family Practice Associates
to release any information acquired in the course of examination or treatment
(For Insurance/Medicare Purposes)
Signed ____________________________________________
Authorization to Pay Benefits to Physician:  I hereby assign payment directly to
Urban Family Practice Associates for services covered by insurance/Medicare. 
I understand that I am personally responsible for all charges.
Signed _____________________________________________
Authorization for Treatment of Minors:  I give consent for myself/son/daughter to undergo examination,
lab work, x-ray and treatment by Urban Family Practice Associates.                 
Signed______________________________________________