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HHHHH.  mmCH m mHmpa^ZY0 (HHHHHHH..HHHHHHHHHHHHHHHH : BLUE RIDGE WOMENS HEALTH CENTER PATIENT REGISTRATION INFORMATION PATIENT INFORMATION LAST NAME ___________________ FIRST _________________ MIDDLE ____________ DATE OF BIRTH _____________ SSN ____________________(OPTIONAL- USED FOR ID PURPOSES) MARITAL STATUS (CIRCLE): MARRIED SINGLE DIVORCED SEPARATED WIDOWED DRIVERS LICENSE ________________________(REQUIRED FOR ID PURPOSES) ADDRESS ______________________________________________________________ PHONE (HOME) _________________________ (WORK) ________________________ (CELL) __________________________ (PLEASE CIRCLE PREFERRED METHOD OF CONTACT) E-MAIL ___________________________________________________________________ EMPLOYER _________________________________________________________________ PRIMARY CARE PHYSICIAN_____________________________________________________ FINANCIALLY RESPONSIBLE PARTY (OTHER THAN PATIENT OR IF PATIENT IS UNDER AGE 18) NAME ____________________________________________________________________ ADDRESS _________________________________________________________________ PHONE (WORK) _______________ (HOME) _________________ (CELL) ______________ DATE OF BIRTH _____________________ EMPLOYER _____________________________ EMERGENCY CONTACT (NAME) ____________________________________________ (PHONE) _________________ RELATIONSHIP_____________ PRIMARY INSURANCE COMPANY NAME _____________________________ POLICY NUMBER _________________ GROUP NUMBER __________________________ EFFECTIVE DATE ____________________ NAME OF POLICY HOLDER _____________________________________________________ ADDRESS OF POLICY HOLDER ___________________________________________________ PHONE (WORK) _________________________ (HOME) _________________________ POLICY HOLDER BIRTHDATE (MM/DD/YYYY) _____________________ RELATIONSHIP TO PATIENT _________________________ SECONDARY INSURANCE COMPANY NAME _____________________________ POLICY NUMBER __________________ GROUP NUMBER __________________________ EFFECTIVE DATE _____________________ NAME OF POLICY HOLDER ______________________________________________________ ADDRESS OF POLICY HOLDER ____________________________________________________ PHONE (WORK) _________________________ (HOME) _________________________ POLICY HOLDER BIRTHDATE (MM/DD/YYYY) _____________________ RELATIONSHIP TO PATIENT _________________________ AUTHORIZATION & RELEASE I authorize release of any information concerning my health care, advice, & treatment provided for the purpose of evaluating & administering claims for insurance benefits. I also hereby authorize payment of insurance benefits otherwise payable to me be made directly to the doctor. I acknowledge that by signing this, I have given permission for this office to treat me. This authorization is effective for five years unless canceled in writing by me. FINANCIAL POLICY Office visit co-payments are due at patient check-in. In the event my account is turned over for outside collection, I agree to pay all costs related to collections, including court costs & attorney fees. I understand that balances over 60 days past due will be assessed a $5.00 or 2% late charge per month, which ever is great, on all unpaid balances. X______________________________________ _________________________________ Signature of Patient (SEAL) Date PRINT & COMPLETE THIS FORM. RETURN TO BLUE RIDGE WOMENS HEALTH CENTER PRIOR TO APPOINTMENT BY PERSONAL DELIVERY TO OFFICE, E-MAIL (not secure), FAX, OR U.S. MAIL: E-MAIL:  HYPERLINK "mailto:BRWHC123PLC@aol.com" BRWHC123PLC@aol.com FAX: 540-433-6605 MAIL: BLUE RIDGE WOMENS HEALTH CENTER, PLC 1885 PORT REPUBLIC ROAD HARRISONBURG, VA 22801  !ABCDWXR S @ A 9 : # $ n o    ! ` a '(vw^_01۶۶۶۶۶۶۶۶۶۶۶۶۶۶۶۶Ƕ۶۶۶۶۶۶۶۶۶۶۶۶ h@h@CJOJPJQJaJ&h@h@5CJOJPJQJ\aJ h@h@CJOJPJQJaJ&h@h@5CJOJPJQJ\aJH!BDXS A : $ o   a ddd[$\$gd@$ddd[$\$a$gd@ (w_1k02pr<ddd[$\$gd@jk/012%opqr{|ll/jh@h@5CJOJPJQJU\aJ2h@h@5>*B*CJOJPJQJ\aJph/h@h@5B*CJOJPJQJ\aJph&h@h@5CJOJPJQJ\aJ&h@h@5CJOJPJQJ\aJ h@h@CJOJPJQJaJ h@h@CJOJPJQJaJ#;<=мh@ h@h@CJOJPJQJaJ&h@h@5CJOJPJQJ\aJ/jh@h@5CJOJPJQJU\aJ.h@h@5>*B*CJOJPJQJ\ph <=21h:p+/ =!"#$% j 666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ OJPJQJ_HmH nH sH tH J`J +Normal dCJ_HaJmH sH tH DA`D Default Paragraph FontRiR 0 Table Normal4 l4a (k ( 0No List 4U`4 @0 Hyperlink >*phPK![Content_Types].xmlj0Eжr(΢Iw},-j4 wP-t#bΙ{UTU^hd}㨫)*1P' ^W0)T9<l#$yi};~@(Hu* Dנz/0ǰ $ X3aZ,D0j~3߶b~i>3\`?/[G\!-Rk.sԻ..a濭?PK!֧6 _rels/.relsj0 }Q%v/C/}(h"O = C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/SeеPK!kytheme/theme/themeManager.xml M @}w7c(EbˮCAǠҟ7՛K Y, e.|,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+& 8PK!Ptheme/theme/theme1.xmlYOo6w toc'vuر-MniP@I}úama[إ4:lЯGRX^6؊>$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! 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