Patient Registration - Oklahoma Oncology

Date Information Verified / By:

Patient Registration

Patient

PATIENT: LAST NAME	FIRST NAME (FULL LEGAL)	MIDDLE NAME

NICKNAME	MAIDEN/PREVIOUS NAME

ADDRESS	CITY	STATE	ZIP CODE	COUNTY

HOME PHONE	CELL PHONE	OTHER PHONE/PAGER	RACE	If Other, please list.

AGE

DATE OF BIRTH

SEX

SOCIAL SECURITY NO.

MARITAL STATUS:

Married

Single

Widowed

Divorced

Separated

HOW WERE YOU REFERRED TO THIS OFFICE?	WHO IS YOUR PRIMARY CARE PHYSICIAN?

Person Responsible For Bill

ADDRESS	CITY	STATE	ZIP CODE	SOCIAL SECURITY NO.

Insurance (Please have your insurance card(s) available when you arrive)

PRIMARY INSURANCE COMPANY NAME	POLICY NO.	GROUP NO.

INSURANCE WITH:
	Private Policy		Employer (Group)

POLICYHOLDER'S NAME (FROM CARD)	SOCIAL SECURITY NO.	DATE OF BIRTH

EMPLOYER NAME (FOR GROUP INSURANCE)

SEND CLAIMS TO

SECONDARY INSURANCE CO. NAME	POLICY NO.	GROUP NO.

SECONDARY INSURANCE WITH:
	Private Policy		Employer (Group)

SEND CLAIMS TO:

ACKNOWLEDGMENT OF NOTICE OF PRIVACY PRACTICES

A complete description of how your medical information will be used and disclosed by this Office Practice is in our NOTICE OF PRIVACY PRACTICES, which you should read before polholdermonthofbirthsigning this agreement. A copy is posted in the Oklahoma Oncology patient waiting area and on the Oklahoma Oncology website.
I have received a copy of Oklahoma Oncology's Notice of Privacy Practices.		Please Intial

AUTHORIZATION FOR MEDICAL TREATMENT

Oklahoma Oncology and its personnel are hereby authorized to administer any medical, diagnostic or therapeutic treatment, including blood transfusions, as may be deemed necessary or advisable. I have the right to consent or refuse consent, to any proposed procedure or therapeutic course, absent emergency or extraordinary circumstances.
Please initial to acknowledge agreement with the statement above.		Please Intial

Emergency Contact (Someone not living in your home)


PATIENT OR AUTHORIZED SIGNATURE	RELATION	DATE

WITNESS		DATE