Nelson Menezes Vascular Specialist PC. Nelson Menezes Vascular Specialist
PC. Page 1 of 2. Medical Office Registration Form. Today's Date: ...
PC.. Nelson Menezes Vascular Specialist PC Medical Office Registration Form Today’s Date:______________
Referred By:_________________
PLEASE BRING WITH YOU TO YOUR APPOINTMENT THE FOLLOWING DOCUMENTS: YOUR MEDICAL INSURANCE CARD(S) AND YOUR PRIMARY CARE PHYSICIAN’S REFERRAL, IF REQUIRED BY YOUR INSURANCE COMPANY.
INFORMATION ABOUT YOU: PATIENT’S NAME:_____________________________ DATE OF BIRTH:___________ AGE:_________ ADDRESS:___________________________________ APT:_____ CITY:__________ STATE:_______ ZIP:________ PHONE- HOME:____________________________ WORK:___________________ S.S. #:______________________
□ UNEMPLOYED
□ RETIRED
□ OTHER______________________________________
NAME OF YOUR EMPLOYER:_______________________________________________________ POSITION:____________________________ ADDRESS:_________________________________________________ NAME OF YOUR MEDICAL INSURANCE CARRIER:__________________________________ POLICY/ID#:_____________________________ MAILING ADDRESS:________________________________________________________________________ DOES YOUR MEDICAL INSURANCE COME FROM YOUR EMPLOYER OR YOUR SPOUSE?:_____________ DO YOU HAVE MEDICARE PART A?
□YES □NO
IF YES, EFFECTIVE DATE:___________
DO YOU HAVE MEDICARE PART B?
□YES □NO
IF YES, EFFECTIVE DATE:___________
WHAT IS YOUR MEDICARE NUMBER?:____________________________________________ WHAT IS YOUR MEDICAID NUMBER?_____________________________________________ DO YOU HAVE A SECONDARY INSURANCE PLAN OR OTHER 20% CO-INS. PLAN?:____________________ IF SO, NAME AND I.D. #:_________________________________
INFORMATION ABOUT YOUR SPOUSE: SPOUSE’S NAME: ___________________________ ADDRESS:___________________________________________ SPOUSE’S EMPLOYER:_________________________________ ADDRESS:_________________________________ SPOUSE’S BIRTHDATE:__________________
