Registration Form

Company Name________________________________________________ Occupation_________________

EMPLOYER

Address____________________________________ Phone_______________� Full-time � Part-time

City _________________________ State _____________ Zip__________Years Employed______________

Name______________________________________ Birthdate____________SSN:_____________________

SPOUSE

              Last Name                   First Name               Initial

(PARENT)

Employer Name____________________________________________ Years Employed_________________

Address_______________________Phone______________________  Occupation_____________________

City___________________________  State ________ Zip________________� Full-time            �  Part-time

PATIENT

Please list any and all insurance and/or employee health care plan coverage you or your spouse may have

INSURANCE

Insurance Company or Health Care Plan Name__________________________________________________

INFORMATION

Policy/Group #:______________________________________   Effective Date:_______________________

Name of Insured:_______________________________________ID #:______________________________

SPOUSE   

Please list any and all coinsurance and/or employee health care plan coverage you or your spouse may have

COINSURANCE

Insurance Company or Health Care Plan Name__________________________________________________

INFORMATION

Policy/Group #:______________________________________   Effective Date:_______________________

Name of Insured:_______________________________________ID #:______________________________

Are your present  symptoms or conditions  related to or the result of an auto accident, work-related injury or other personal injury  someone else might be legally liable for?  � Yes   � No     Your Initials:__________

MEDICAL

If you answered yes, please fill out accident specific form, available at the front desk.

AND LEGAL

Pregnant  �  Yes  �  No      Pacemaker   � Yes   � No        Family Physician__________________________

INFORMATION

Person to contact in emergency (Name and Phone #)_____________________________________________

Attorney_________________________________________________ Telephone:______________________

Address_________________________________________________________________________________

PATIENT AGREEMENT

LEGAL ASSIGNMENT OF BENEFITS AND RELEASE OF MEDICAL AND PLAN DOCUMENTS

    In considering the amount of medical expenses to be incurred, I, the undersigned, have insurance and/or employee health care benefits coverage with the above captioned, and hereby assign and convey directly to PMC all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services rendered from such doctor and clinic. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the doctor to release all medical information necessary to process this claim. I hereby authorize any plan administrator or fiduciary, insurer and my attorney to release to such doctor and clinic any and all plan documents, insurance policy and/or settlement information upon written request from such doctor and clinic in order to claim such medical benefits, reimbursement or any applicable remedies.  I authorize the use of this signature on all my insurance and/or employee health benefits claim submissions.

    I hereby convey to the above named doctor and clinic to the full extent permissible under the law and under the any applicable insurance policies and/or employee health care plan any claim, chose in action, or other right I may have to such insurance and/or employee health care benefits coverage under any applicable insurance policies and/or employee health care plan with respect to medical expenses incurred as a result of the medical services I received from the above named doctor and clinic and to the extent permissible under the law to claim such medical benefits, insurance reimbursement and any applicable remedies.  Further, in response to any reasonable request for cooperation, I agree to cooperate with such doctor and clinic in any attempts by such doctor and clinic to pursue such claim, chose in action or right against my insurers and/or employee health care plan, including, if necessary, bring suit with such doctor and clinic against such insurers and/or employee health care plan in my name but at such doctor and clinic's expenses.

    Should this assignment be prohibited in part or in whole under any anti-assignment provision of my policy/plan, please advise and disclose to my provider in writing such anti-assignment provision within 30 days upon receipt of my assignment, otherwise this assignment should be reasonably expected to be effective and such anti-assignment is waived.

    This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original.  I have read and fully understand this agreement.

____________________________________________________        _____________________________

       Signature of Insured / Guardian                                                                               Date