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The form captures patient demographics, contact information, responsible party details when applicable, and primary/secondary insurance policy holder information. It includes emergency contact data, consent to disclose patient health information, authorization to release medical information, Medicare applicability certification, benefits assignment, and payment guarantee terms. It also covers electronic prescriptions authorization, immunization registry submission consent, and signature confirmation.","Patient Registration\nIs this injury work, or motor vehicle accident related?    YES   NO (circle one)\nPATIENT INFORMATION:\nLast Name: ________________________First Name: ______________________Middle Initial:________ Date of Birth:_____________\nMailing Address\t\t\t\t\tCity:                                                                State:\t\tZip:\nPhone Number: Home\t\t\t\t\t(voicemail Y / N )  Cell:_____________________(voicemail Y / N )\nGender:  M /  F   Social Security #:\t\t\t\t   Marital Status: ___________ Race:________ Ethnicity:__________\nRESPONSIBLE PARTY INFORMATION (if different from above):  Relationship to patient: _____________________\nLast Name:\t\t\t\t\tFirst Name:\t\t\tMiddle Initial:\t Mailing Address:\t\t\t\t\tCity:\t\tState:\t\tZip: ___________\nPhone Number: Home\t\tCell: ____________________Work: ________________Date of Birth: _______________\nINSURANCE POLICY HOLDER INFORMATION\nPrimary\nInsurance Name:\t\t\tSubscriber ID#:\tGroup#: _______________\nInsurance Address:__________________________________________________________________________________________\nInsurance City/State/Zip: ________________________________________________Effective Date: ______________________\nSubscriber Name (If different from above): ___________________________Date of Birth: _______________\nRelationship to patient: ___________________________________________\nSecondary\nInsurance Name:\t\t\tSubscriber ID#:\tGroup#: ___________\nInsurance Address:___________________________________________________________________________________________\nInsurance City/State/Zip: ________________________________________________Effective Date: _____________________\nSubscriber Name (If different from above): ___________________________Date of Birth: _______________\nRelationship to patient: ___________________________________________\n* Emergency Contact:\tPhone #:\nI authorize Favia Primary Care to disclose my Patient Health Information to the following person(s):\nName: ____________________ Phone Number: ________________________ Relationship: ____________________\nName: ____________________ Phone Number: ________________________ Relationship: ____________________\nAUTHORIZATION TO RELEASE INFORMATION:\nI hereby authorize Favia Primary Care and its agents to release any medical or incidental information that may be necessary for either medical care, to submit a health insurance claim, in processing applications for financial benefits, for quality assurance, or for Favia Primary Care review for the purpose of medical research.\nAPPLICABLE TO MEDICARE PATIENTS:\nI certify that the information given by in in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration and/or the Medicare program or its intermediaries or carriers any information needed for this or related Medicare claims. I request that the payment of authorized benefits be made on my behalf\nASSIGNMENT OF BENEFITS:\nI hereby authorize direct payment direct payment of medical benefits to Favia Primary Care for services rendered. I understand that I am financially responsible to Favia Primary Care for charges not covered by this assignment. In some cases, your provider fee is not covered in full by your insurance company. This balance due includes provisions set by your insurance company such as copayments, deductibles, and “usual and customary” allowance.\nGUARANTEE OF PAYMENT:\nIn consideration of all medical services given by Favia Primary Care to the patient named above, I agree to pay Favia Primary Care all fees and charges made for services, which may include the cost of collection and/or reasonable attorney’s fees. Payment is due and payable within 30 days of billing date. A late charge may be added to the account for all charges not paid within 90 days.  If your account is turned over to a collection agency you will be responsible for the 35% service charge.\nI hereby certify that the foregoing information is true","cbCaidySflR2EilU","https://ap.wps.com/l/cbCaidySflR2EilU","docx",114931,"English","en",105,"# Patient Information\n## Responsible Party Information\n## Insurance Policy Holder Information\n# Authorizations and Payment Terms\n## Emergency Contact and Release Consent\n## Medicare Certification\n## Assignment of Benefits and Guarantee of Payment\n# Electronic Records and Signature\n## Electronic Prescriptions Authorization\n## Immunizations Registry Submission","[{\"question\":\"What information is required for the Patient Information section?\",\"answer\":\"The form requests last name, first name, middle initial, date of birth, mailing address, city/state/zip, phone numbers, gender, Social Security number, marital status, race, and ethnicity.\"},{\"question\":\"When is the Responsible Party Information section used?\",\"answer\":\"Use it when the responsible party is different from the patient; it collects relationship to the patient plus the responsible party’s identity, address, phone numbers, and date of birth.\"},{\"question\":\"What consents and authorizations does the form include?\",\"answer\":\"It authorizes Favia Primary Care to disclose and release medical information for care and claims, includes Medicare-related certification for applicable patients, and authorizes electronic prescription access and immunization data submission to the I-CARE registry.\"}]","Patient Registration - Form | DOCX",1788220521,{"code":4,"msg":29,"data":30},"ok",{"site_id":23,"language":22,"slug":31,"title":14,"keywords":32,"description":15,"schema_data":33,"social_meta":85,"head_meta":87,"extra_data":89,"updated_unix":27},"patient-registration-form","",{"@graph":34,"@context":84},[35,52,67],{"@type":36,"itemListElement":37},"BreadcrumbList",[38,42,46,49],{"item":39,"name":40,"@type":41,"position":11},"https://docshare.wps.com","Home","ListItem",{"item":43,"name":44,"@type":41,"position":45},"https://docshare.wps.com/template/","Template",2,{"item":47,"name":13,"@type":41,"position":48},"https://docshare.wps.com/template/forms/",3,{"item":50,"name":14,"@type":41,"position":51},"https://docshare.wps.com/template/patient-registration-form/167861/",4,{"url":50,"name":14,"@type":53,"author":54,"headline":14,"publisher":56,"fileFormat":59,"inLanguage":22,"description":15,"dateModified":60,"datePublished":61,"encodingFormat":59,"isAccessibleForFree":62,"interactionStatistic":63},"DigitalDocument",{"name":9,"@type":55},"Person",{"url":39,"name":57,"@type":58},"DocShare","Organization","application/vnd.openxmlformats-officedocument.wordprocessingml.document","2026-09-04","2026-08-31",true,{"@type":64,"interactionType":65,"userInteractionCount":51},"InteractionCounter",{"@type":66},"ViewAction",{"@type":68,"mainEntity":69},"FAQPage",[70,76,80],{"name":71,"@type":72,"acceptedAnswer":73},"What information is required for the Patient Information section?","Question",{"text":74,"@type":75},"The form requests last name, first name, middle initial, date of birth, mailing address, city/state/zip, phone numbers, gender, Social Security number, marital status, race, and ethnicity.","Answer",{"name":77,"@type":72,"acceptedAnswer":78},"When is the Responsible Party Information section used?",{"text":79,"@type":75},"Use it when the responsible party is different from the patient; 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