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

EMPLOYER'S NAME	OCCUPATION	LENGTH OF EMPLOYMENT

EMPLOYER'S ADDRESS		BUSINESS PHONE

SPOUSE'S LAST NAME	FIRST NAME	SOCIAL SECURITY NO.

SPOUSE'S EMPLOYER'S NAME		BUSINESS PHONE

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

Person Responsible For Bill

RESPONSIBLE PARTY: LAST NAME	FIRST NAME (FULL LEGAL)	MIDDLE INITIAL

RELATION	HOME PHONE

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.	MONTH 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:

Emergency Contact (Someone not living in your home)

	NAME:	RELATION:	PHONE:	OTHER PHONE/PAGER:
1.
2.

I authorize all benefits to be assigned and payable directly to Oklahoma Oncology, Inc. I understand that I am responsible to pay all medical services not covered by an authorization / agreement between my physician and my insurance company.


PATIENT OR AUTHORIZED SIGNATURE	RELATION	DATE

WITNESS		DATE