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PATIENT REGISTRATION TEST

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PATIENT REGISTRATION FORM

First Name:
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Middle Name:
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Last Name:
Your Last Name
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Home Address:
Your Address
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Apartment or Suite #
Enter Apt or Suite #
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City
City
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State
  • - select a state -
  • Alabama
  • Alaska
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  • Arkansas
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  • Colorado
  • Connecticut
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  • District of Columbia
  • Florida
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  • New Hampshire
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  • South Dakota
  • Tennessee
  • Texas
  • Utah
  • Vermont
  • Virginia
  • Washington
  • West Virginia
  • Wisconsin
  • Wyoming
- select a state -
Field is required!
Zip Code:
Zipcode
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Have You Been a Patient Here Before?
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Sex:
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Marital Status:
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Birth Date:
Date of Birth
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Social Security #:
Your Social Security #
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Phone #:
Your Phone Number
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Emergency Contact First Name
Your Emergency Contact First Name
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Emergency Contact Last Name:
Your Emergency Contact Last Name
Field is required!
Relationship to Patient:
Your Relationship to Patient:
Field is required!
Emergency Contact Address:
Your Emergency Contact Address:
Field is required!
Emergency Contact Phone Number:
Your Emergency Contact Phone Number
Field is required!
Is the responsible billing party different from the patient? If no, continue to next screen.
Field is required!
Responsible Party First Name:
Your Responsible Party First Name
Field is required!
Responsible Party Last Name:
Responsible Party Last Name
Field is required!
Relationship to Patient:
Your Relationship to Patient:
Field is required!
Responsible Party Address:
Your Responsible Party Address:
Field is required!
Responsible Party Phone Number:
Your Responsible Party Phone Number
Field is required!
Employer Name:
Your Employer Name
Field is required!
Employer Address:
Your Employer Address
Field is required!
Income:
Your Income
Field is required!
Relationship:
Your Relationship to Patient
Field is required!
Age:
Your Age
Field is required!
Gross Monthly Income:
Your Gross Monthly Income
Field is required!
Total Persons in Household:
Total Persons in Household:
Field is required!
Total Gross Income:
Your Total Gross Income
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Is there any addtional income?:
  • - select a option -
  • Yes
  • No
- select a option -
Field is required!
Enter Additional income amount:
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Is this Patient Covered by Insurance?
(If you checked 'No' please skip this section)
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Please indicate Primary Insurance:
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Person Responsible for Charges:
Person Responsible for Charges
Field is required!
Responsible Party Phone Number:
Responsible Party Phone #
Field is required!
Responsible Party Birtthdate:
Responsible Party Birtthdate
Field is required!
Responsible Party Address:
Responsible Party Address
Field is required!
Group Name:
Group Name
Field is required!
Group Number:
Group Number
Field is required!
Subscriber's SSN:
Subscriber's SSN
Field is required!
Policy Number:
Policy Number
Field is required!
Co-Payment Amount $:
Enter the amount
Field is required!
Patient's Relationship to Subscriber:
Field is required!
Preferred Language?
  • - select a option -
  • English
  • Spanish
  • Other
- select a option -
Field is required!
Are You a Veteran of the Armed Forces?
  • - select a option -
  • Yes
  • No
- select a option -
Field is required!
Are You Homeless?
  • - select a option -
  • Yes
  • No
- select a option -
Field is required!
Race:
  • - select a option -
  • White
  • Asian
  • African American
  • Pacific Islander
  • American Indian
  • More Than One Race
  • Unknown
- select a option -
Field is required!
Latino or Hispanic Descent?
  • - select a option -
  • Yes
  • No
- select a option -
Field is required!
How Did You Hear about MHC?
  • - select a option -
  • PCP
  • Commercial
  • Social Media
  • Billboard
  • Referral
  • Family or Friend
- select a option -
Field is required!
Submit

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