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Indian or Alaska Native  \n□ Asian  \n□ Black or African American  \nEdison Surgery Center  \n# Patient Registration Form\n\nSocial Security Number:                                                                                                \n                    Work Phone:                     \n                        _City:_               \n                                             _(for you to access your health information electronically)  \n□ Partnered □ Widowed  \nFor Government Healthcare Analysis Use  \n□More Than One Race  \n□Native Hawaiian  \n□ Other Pacific Islander  \n_City:_                   \nCell Phone:_            \nState:_____Zip_      \nPhone:                            \nRelationship:_                    \n□ White  \n□Do Not Wish To Provide  \nRace (Only Check One Selection)  \n□ American Indian or Alaska Native  \n□ More Than One Race  \n□White  \n□ Asian  \n□ Native Hawaiian  \n□ Do Not Wish To Provide  \n□ Black or African American  \n□ Other Pacific Islander  \nEthnicity (Only Check One Selection)  \n□ Hispanic or Latino  \n□Do Not Wish To Provide  \n□ Not Hispanic or Latino  \nPrimary /Preferred Language (Only Check One Selection)  \n□ Chinese  \n□ Hindi  \n□ English  \n□ Italian  \n□ Korean  \n□ Spanish  \n□ Vietnamese  \n□ American Sign Language  \n□ Other  \n                                                          □Do Not Wish To Provice  \nPrimary Insurance Information  \nSecondary Insurance Information  \nInsurance Company Name:  \n                                Insurance Company Name:                  \n□ The insured policy holder is the patient  \n□ The insured policy holder is the patient  \n(if under spouse,fill in spouse's name and dob)(if under spouse,fillin spouse's name and dob)  \nInsured's Name:  \n                         Insured's Name:                           \nInsured's Date of Birth:                                                \nInsured's Date of Birth:                                                \n_Insured's Social Security\\#:_                  \nInsured's Social Security\\#:_  \n                   \n# Authorization For Release of Information &Assignment of Benefits\n\nCommerical Insurance Patients:I AUTHORIZE the release of any medical information necessary to process my insurance claims.IAUTHORIZE and request payment of medical benefits directly to my physicians.IAGREE that authorization will cover all medicalservices rendered until such authorization is revoked by me.I AGREE that a photocopy of this form may be used in place of theoriginal.  \nSignature:  \n                            Date:                          \nMedicare Patients:I AUTHORIZE any holder of medical or other information about me to release to the Socia Security  \nAdministration and Center for Medicare and Medicaid Services (CMS)or its intermediaries or carriers any information needed for thisor related Medicare claim.I permit a copy of this authorization to be used in place of the original and request payment of medicalinsurance benefits either to myself or to the party who accepts assignment.I UNDERSTAND it is mandatory to notify the healthcareprovider of any other party who may be responsible for paying for my treatment.Regulations pertaining to Medicare assgnment ofbenefits also apply.  \nSignature:  \n                                    Date:                                 \n## ***TO ALL PATIENTS:HIPAA NOTICE***HEALTH INSURANCE PORTABILITY &ACCOUNTABILITY ACT\n\nI acknowledge that I have received our Notices of Privacy Practices Brochure:  \n                              Date:                           \nSignature:  \n\n|  |\n| --- |\n\nMember ID Number:                                                            \nEDISON SURGERY CENTER  \n10 Parsonage Road,Ste 206Edison,NJ 08837Billing department:732-441-7177Fax:732-441-7165  \n## ASSIGNMENT OF BENEFITS\n\n                  Date of Birth:         ","cbCaicVYmzfyCjEG","https://ap.wps.com/l/cbCaicVYmzfyCjEG","pdf",5317891,"English","# Patient Registration Form\n## Authorization For Release of Information & Assignment of Benefits\n## Assignment of Benefits\n## Acknowledgment and Agreement Regarding Insurance Company Payments\n## HIPAA Notice","[{\"question\":\"What information does the Patient Registration Form collect?\",\"answer\":\"It collects patient demographics, emergency contact details, race and ethnicity selections, primary/preferred language, and primary and secondary insurance information.\"},{\"question\":\"What does the Authorization For Release of Information section allow?\",\"answer\":\"It authorizes the release of necessary medical information to process insurance claims, and it requests payment of medical benefits to the appropriate physicians or for services covered.\"},{\"question\":\"What does the Assignment of Benefits section require from the patient or responsible party?\",\"answer\":\"It directs the insurance carrier or payor to pay Edison Surgery Center directly for benefits related to treatment, and it includes agreement to cooperate and allow follow-up and legal processes as permitted by law.\"}]","Patient Registration Form - Authorization For Release of Information & Assignment of Benefits | PDF",1789634343]