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Memphis Health Center

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Demo Information
Memphis Health Center

PATIENT REGISTRATION FORM


Please note that fields marked with * are mandatory.

PATIENT INFORMATION

* Patient Last Name: * First: Middle: * Have You Been to MHC Before?:
Yes No
* Home Address: Apt/Suite: * City: * State: * Zip Code:
* Sex: * Birth Date: * Social Security #: * Phone Number: * Marital Status:
M F
Single Married Divorced Other

EMERGENCY CONTACT

* Name: * Relationship to Patient: Address: * Phone Number:

RESPONSIBLE PARTY (IF DIFFERENT FROM ABOVE)

Name: Relationship to Patient: Address: Phone Number:

INCOME INFORMATION

Employer: Employer Address:
Name: Relationship: Age: Gross Monthly Income:
Total Persons:
Total Gross Income:

INSURANCE INFORMATION

* Do You Have Insurance? Yes No (If 'No,' please skip this section)
* Please indicate Primary Insurance: Medicare SCHIP TN Care Other:
* Person Responsible for Charges: * Birth Date: * Address: (if different): Home Phone:
* Subscriber's SSN: Group Name: Group Number: Policy Number: Co-Payment: $
* Patient's Relationship to Subscriber: Self Spouse Child Other:
Secondary Insurance: Subscriber's Name: Subscriber's SS#: Birth Date: Group Number: Policy Number:
Patient's Relationship to Subscriber: Self Spouse Child Other:

ADDITIONAL INFORMATION

* Preferred Language:
English Spanish Other:
* Are You a Veteran of the Armed Forces?
Yes No
* Are You Homeless?
Yes No
Race:
White   Asian   African American   Pacific Islander
American Indian   More Than One Race   Unknown
Latino/Hispanic Descent?
Yes   No
* How Did You Hear about MHC? Relative/Friend School Hospital Church Direct Mail Internet
Magazine Newspaper Radio A Step Ahead CAAP Health Fair/Community Event Other:
INSURANCE ASSIGNMENT
I hereby authorize: (a) payment of insurance benefits otherwise due to me be made directly to Memphis Health Center, Inc.; (b) release of information, including protected health information, to insurance companies as needed to file for payment of services incurred; (c) Memphis Health Center, Inc. to obtain records from other sources as may be necessary in my diagnosis or treatment; and, (d) that I am financially responsible to Memphis Health Center, Inc. for charges related to services provided or incurred by me or the party I am responsible for.

I certify that all statements made in this form are true, complete and accurate to the best of my knowledge. I understand that if I am eligible for the sliding fee discount, my eligibility will expire six (6) months from today's date.
Signature: Date: Friday, Jun 23, 2017
PATIENT REGISTRATION FORM PG 1
Revised 8/11 BW