Medical Administration Module 3

Company Name, Street Address, City, State ZIP Code, phone number

[NAME OF PRACTICE] REGISTRATION FORM

(Please Print)

Today’s date: PCP:

PATIENT INFORMATION Patient’s last name: First: Middle:  Mr.

 Mrs.  Miss  Ms.

Marital status (circle one)

Single / Mar / Div / Sep / Wid

Is this your legal name? If not, what is your legal name? (Former name): Birth date: Age: Sex:

 Yes  No / /  M  F

Street address: Social Security no.: Home phone no.:

( )

P.O. box: City: State: ZIP Code:

 

Occupation: Employer: Employer phone no.:

( )

Chose clinic because/Referred to clinic by (please check one box):  Dr.  Insurance Plan  Hospital

 Family  Friend  Close to home/work  Yellow Pages  Other

Other family members seen here:

 

INSURANCE INFORMATION (Please give your insurance card to the receptionist.)

Person responsible for bill: Birth date: Address (if different): Home phone no.:

/ / ( )

Is this person a patient here?  Yes  No

Occupation: Employer: Employer address: Employer phone no.:

( )

Is this patient covered by insurance?  Yes  No

Please indicate primary insurance  [Insurance]  [Insurance]  [Insurance]  [Insurance]  [Insurance]

 [Insurance]  [Insurance]  [Insurance]  Welfare (Please provide coupon)  Other

Subscriber’s name: Subscriber’s S.S. no.: Birth date: Group no.: Policy no.: Co-payment:

/ / $

Patient’s relationship to subscriber:  Self  Spouse  Child  Other

Name of secondary insurance (if applicable): Subscriber’s name: Group no.: Policy no.:

 

Patient’s relationship to subscriber:  Self  Spouse  Child  Other

 

IN CASE OF EMERGENCY Name of local friend or relative (not living at same address): Relationship to patient: Home phone no.: Work phone no.:

( ) ( )

The above 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 [Name of Practice] or insurance company to release any information required to process my claims.

Patient/Guardian signature Date

 

1. Todays date:
2. PCP:
3. Patients last name First Middle:
4. salutation:
5. salutation_2:
6. Yes:
7. No:
8. If not what is your legal name:
9. Former name:
10. Birth date:
11. Age:
12. Sex:
13. Street address:
14. Social Security no:
15. Home phone no:
16. PO box:
17. City:
18. State:
19. ZIP Code:
20. Occupation:
21. Employer:
22. Employer phone no:
23. Chose clinic becauseReferred to clinic by please check one box:
24. Family:
25. Friend:
26. Close to homework:
27. Other:
28. Yellow Pages:
29. Dr:
30. Insurance Plan:
31. Hospital:
32. Other family members seen here:
33. Person responsible for bill:
34. Birth date_2:
35. Address if different:
36. Home phone no_2:
37. Is this person a patient here Yes No:
38. undefined:
39. undefined_2:
40. Occupation_2:
41. Employer_2:
42. Employer address:
43. Employer phone no_2:
44. Is this patient covered by insurance Yes No:
45. undefined_3:
46. undefined_4:
47. Insurance:
48. Insurance_2:
49. Insurance_3:
50. Insurance_4:
51. Insurance_5:
52. Welfare Please provide:
53. Insurance_6:
54. Insurance_7:
55. Insurance_8:
56. Other_2:
57. Subscribers name:
58. Subscribers SS no:
59. Birth date_3:
60. Group no:
61. Policy no:
62. Patients relationship to subscriber Self Spouse Child Other:
63. undefined_5:
64. undefined_6:
65. undefined_7:
66. undefined_8:
67. Name of secondary insurance if applicable:
68. Subscribers name_2:
69. Group no_2:
70. Policy no_2:
71. Patients relationship to subscriber Self Spouse Child Other_2:
72. undefined_9:
73. undefined_10:
74. undefined_11:
75. undefined_12:
76. Name of local friend or relative not living at same address:
77. Relationship to patient:
78. Date:

Module 03 Course Project – Part 1

PATIENT REGISTRATION FORM

 Practice – The People’s Clinic

 Address – 1000 Town Square, Anytown Pennsylvania 54321

 Phone – 555-741-8529

 

PATIENT INFORMATION

 Patient – Mrs. Jane Doe

 Married

 Former name – Jane Smith

 DOB – 01/01/1960

 SSN – 123-45-6789

 Address – 123 Main Street, Anytown Pennsylvania 54321

 Phone – 555-987-6543

 Occupation – Nurse

 Employer – The People’s Hospital

 Employer Phone – 555-456-7890

 Doctor referral to clinic

 

INSURANCE INFORMATION

 Jane Doe is responsible for payment

 Primary insurance is Blue Cross Blue Shield

 Subscriber – Jane Doe

 ID – 123123123

 Grp – 00550055

 No secondary insurance

 

IN CASE OF EMERGENCY

 Suzie Smith (sister)

 Home – 555-567-8910

 Work – 555-678-9012

 

 

 

OUTPATIENT ENCOUNTER FORM

Jane Doe (chart #0987) saw Dr. Brown on 1-1-2015.

She is 5’5’’ tall and weighs 130 pounds

Her blood pressure was 120/70

Her pulse was 60

Her temperature was 98.6

 

This was her second visit with Dr. Brown after she was referred by Dr. White. She is seeing Dr. Brown

for adult onset IDDM (insulin dependent diabetes mellitus). Medical Administration Module 3

 

Jane’s visit was only for an office visit and laboratory tests. Dr. Brown spent 25 minutes with Jane at this

visit and ordered lab testing for Hemoglobin A1C. Jane needs to return to see Dr. Brown in 1 month.

 

When Jane checked out she gave the receptionist her encounter form which had the office visit at a cost

of $100. She paid the amount of her copayment which was $20.