METROPOLITAN FAMILY CARE, INC. Today’s Date: ____/____/______ REGISTRATION FORM (Please PRINT) PATIENT INFORMATION Patient’s Last Name: First: Middle: Mr. Mrs. Sr. Dr. Miss. Jr. Street Address City State Zip Code Home Phone #: Work/Cell Phone #: E-mail Address: Birth Date Age Social Security Number Marital Status Sex Single Widowed Male / / Married Female Divorced INSURANCE INFORMATION Occupation: Insured Employer Insured Employer Address Address of Primary Insurance Carrier Phone Number Please Indicate Primary Insurance Insured Name Insured SSN # Insured ID # Policy Group # Effective Date Co-Payment $ Patient’s Relationship to Insured Insured Birth Date Self Spouse Child Other Insurance Type PPO EPO Self-Pay Public Aid HMO POS Medicare WC Please Indicate Secondary Insurance Address of Secondary Insurance Phone Number: Insured Name Insured SSN # Insured ID # Policy Group # Effective Date Co-Payment $ Insured Birth Date Patient’s Relationship to Insured Self Spouse Child DEMOGRAPHCS (FOR GOVERNMENTAL STATISTICAL ANALYSIS) American Indian/ Asian Native Hawaiian Black or African American Race: Alaska Native Hispanic Other Pacific Islander I Decline to Report Ethnicity: Hispanic Non-Hispanic I Decline to Report Preferred English Spanish Other______________________________________ Language: AUTHORIZATION FOR ASSIGNMENT X_________________________________________________ OF BENEFITS Signature Date HIPAA AUTHORIZATION X_________________________________________________ Signature Date Metropolitan Family Care, Inc. 3341 East Livingston Avenue, Suite D Columbus, Ohio 43227 (614) 237-1067 Fax: (614) 237-2655
METROPOLITAN FAMILY CARE, INC. Today’s Date: ____/____/______ REGISTRATION FORM (Please PRINT) PATIENT INFORMATION Patient’s Last Name: First: Middle: Mr. Dr. Mrs. Miss. Sr. Jr. Street Address City State Zip Code Home Phone #: Work/Cell Phone #: E-mail Address: Birth Date Age Social Security Number Marital Status Sex / / Single Widowed Married Divorced Male Female INSURANCE INFORMATION Occupation: Insured Employer Insured Employer Address Please Indicate Primary Insurance Address of Primary Insurance Carrier Phone Number Insured Name Insured SSN # Insured ID # Policy Group # Effective Date Co-Payment $ Patient’s Relationship to Insured Self Spouse Child Other Insured Birth Date Insurance Type PPO HMO EPO POS Self-Pay Medicare Public Aid WC Please Indicate Secondary Insurance Address of Secondary Insurance Phone Number: Insured Name Insured SSN # Insured ID # Policy Group # Effective Date Co-Payment $ Patient’s Relationship to Insured Self Spouse Child Insured Birth Date DEMOGRAPHCS (FOR GOVERNMENTAL STATISTICAL ANALYSIS) Race: American Indian/ Alaska Native Asian Hispanic Native Hawaiian Other Pacific Islander Black or African American I Decline to Report Ethnicity: Hispanic Non-Hispanic I Decline to Report Preferred Language: English Spanish Other______________________________________ AUTHORIZATION FOR ASSIGNMENT X_________________________________________________ OF BENEFITS Signature Date HIPAA AUTHORIZATION X_________________________________________________ Signature Date Metropolitan Family Care, Inc. 3341 East Livingston Avenue, Suite D Columbus, Ohio 43227 (614) 237-1067 Fax: (614) 237-2655
MFC-Yearly-Info-Update-MASTER.docx