Cardiology Associates Patient Registration

Patient Information:

Last Name: First Name:  Middle:

Street Address:       Apt   

City:         State:        Zip Code:    

Phone Numbers:  Home:       Work:   Cell:

Email:    DOB:  Month 1 2 3 4 5 6 7 8 9 10 11 12 Day     1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year SS#    

Marital Satus:  Single Married Divorced Separated Widowed   Visit related to?  Work Injury? No Yes   Motor vehicle accident? No Yes

Employer:    Allergies:

Primary Care Physician:  Name: Address:   Telephone:

Referring Physician:  Name: Address:   Telephone:

Pharmacy:  Name: Address:   Telephone:

__________________________________________________________________________________________

Emergency Contacts:
Please list TWO emergency contacts (one that does not reside with you):
 Name  Telephone Relationship Name  Telephone   Relationship

___________________________________________________________________________________________________________________________________

If the person responsible for the bill is NOT the patient, please complete this section:
Person Responsible for the bill   Relationship to Patient Their SS #

Their Birthdate: Their Phone # Their Address (if different than patient:

______________________________________________________________________

 Insurance Information:       NONE 

                                    PRIMARY INSURANCE:                     SECONDARY INSURANCE:

Insurance Company:                                

Street Address:                                     

         City   State   Zip:                          City   State   Zip:

Subscriber's Name:                                   Subscriber's Name: 

Subscriber: DOB: Month 1 2 3 4 5 6 7 8 9 10 11 12 Day  1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year SS#   Subscriber: DOB: Month 1 2 3 4 5 6 7 8 9 10 11 12 Day  1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year SS#

ID:   Group #  COPAY:            ID:   Group #  COPAY:

______________________________________________________________________

ASSIGNMENT AND RELEASE: I hereby authorize my insurance benefits to be paid directly to Cardiology Associates of Schenectady, PC
 and acknowledge that I am financially responsible for any unpaid balance.  I also authorize the release of any information required
 in the course of my examination or treatment to my insurance company.

I Agree     Month 1 2 3 4 5 6 7 8 9 10 11 12 Day  1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year

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