Patient Registration

Information

Insurance cards copied

Date:

08/28/2014

Account#:

Please PRINT AND complete ALL sections below!

YES NO

Is your condition a result of a work injury

PATIENTS PERSONAL INFORMATION
Name:
Lofton

An auto accident? YES NO

Single Married Divorced Widowed

Shanyce

Last Name

Street Address:
Home Phone:
Date of Birth:

Mo.

Day

Sex: Male Female

SW
Initial

State:

NC
235-

Zip:
25

28401
-2458

Year

Full Time Part Time

Spouses Work phone: (910 ) 555-3264

Planning Management Group

Philip
Last Name

How do you wish to be addressed?

First Name

Initial

Shanyce Lofton

Social Security #:

PATIENTS/RESPONSIBLE PARTY INFORMATION

Responsible party: Shanyce Lofton
Relationship to Patient: Self Spouse Other
Responsible Partys home phone:
(910 ) 555-9652
Address:
623 Chicken Drive
Apt#
Employers Name:
Planning Management Group
Address:
5665 Duck Lane
Apt#
Your Occupation:
Planner
Spouses Employer Name:
PPD
Address:
8455 Gray Avenue
PATIENTS INSURANCE INFORMATION
PRIMARY insurance companys name: Tricare
Insurance address:
1215 Orange Avenue
Name of insured:
Shanyce Lofton
Insurance ID number: 1651451
Check if appropriate:

Date of injury:

First Name

623 Chicken Drive

Apt # A City:
Wilmington
(910 ) 555-9652
Work Phone: (910 )555-3256
Social Security #:
02/ 18 /1989 Drivers License: (State & Number)
NC 236548

Employer/Name of School:
Spouses Name: Lofton

Insurance #:
Co-Payment: $

Medigap policy

Date of Birth:
Social Security #:
Work Phone: ( 910)550-3256
City: Wilmington
State:
Phone No:
( 919) 235-9582
City: Wilmington
State:

A
4

City:

Wilmington

235-

25

-2458

02
235-

18
25

/1989
-2458

NC

Zip:

28401

NC

Zip:

28401

Spouses Work phone: (958 )325-2515

State: NC Zip: 28401

Please present insurance cards to receptionist.

City: Wilmington
State: NC Zip: 28401
Date of Birth: 02/18/1989
Relationship to insured: Self
Group number:

Retiree coverage

PATIENTS REFERRAL INFORMATION

Referred by:
Friend
Name(s) of other physician(s) who care for you:

If referred by a friend, may we thank her/him?

YES NO

EMERGENCY CONTACT
Name of person not living with you:
Philip Lofton
Address:
623 Chicken Lane
Phone number (home):
( 910)555-9652

Relationship: Spouse
City: Wilmington
State: NC
Phone number (work)
( 958) 325-2515

Zip:

28401

Assignment of Benefits Financial Agreement

I hereby give lifetime authorization for payment of insurance benefits to be made directly to
Wilmington Health Associates
, and
any assisting physicians, for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by
insurance. In the event of default, I agree to pay all costs of collection, and reasonable attorneys fees. I hereby authorize this healthcare
provider to release all information necessary to secure the payment of benefits.
I further agree that a photocopy of this agreement shall be as valid as the original.

Date:
08/28/2014
Method of payment:

Your Signature:
Betty Whiteville
Cash Check Credit Card
PATIENT REGISTRATION