MEMPHIS VASCULAR CENTER PATIENT REGISTRATION Patient Information Last Name First: MI Address City/State/Zip Phone-Home Cell Phone Date of Birth SS No. Refered to see: Sex: Martial Status: Referred By: Physician Friend/Relative Other: Referring MD/PCP Physician Phone Physician Address City/State/Zip Employer Employer Phone Employer Address City/State/Zip Emergency Contact Contact Phone Contact Address City/State/Zip Responsible Party Last Name First MI Address City/State/Zip Phone-Home DOB SS No. Employer Employer Phone Employer City/State/Zip Insurance Information Primary Insurance Policy No. Group No. Policy Holder Ins. Phone DOB Policy Holder Address SS No. Referral No. Other Insurance Co. Policy No. Group No. Policy Holder SS No DOB Policy Holder Address City/State/Zip I hereby authorize (a) payment of insurance benefits otherwise due to me to be made directly to the treating physician, (b) release of information including protected health information to insurance companies as needed to file for payment for services incurred, (c) Memphis Vascular Center to obtain and submit records as may be necessary in the diagnosis or treatment, and (d) understand that I am financially responsible for payment to Memphis Vascular Center for charges related to service provided to or incurred by me or my dependents.
MEMPHIS VASCULAR CENTER PATIENT REGISTRATION Patient Information Last Name First: MI Address City/State/Zip Phone-Home Cell Phone Date of Birth SS No. Refered to see: Sex: Martial Status: Referred By: Physician Friend/Relative Other: Referring MD/PCP Physician Phone Physician Address City/State/Zip Employer Employer Phone Employer Address City/State/Zip Emergency Contact Contact Phone Contact Address City/State/Zip Responsible Party Last Name First MI Address City/State/Zip Phone-Home DOB SS No. Employer Employer Phone Employer City/State/Zip Insurance Information Primary Insurance Policy No. Group No. Policy Holder Ins. Phone DOB Policy Holder Address SS No. Referral No. Other Insurance Co. Policy No. Group No. Policy Holder SS No DOB Policy Holder Address City/State/Zip I hereby authorize (a) payment of insurance benefits otherwise due to me to be made directly to the treating physician, (b) release of information including protected health information to insurance companies as needed to file for payment for services incurred, (c) Memphis Vascular Center to obtain and submit records as may be necessary in the diagnosis or treatment, and (d) understand that I am financially responsible for payment to Memphis Vascular Center for charges related to service provided to or incurred by me or my dependents.