Lone Star Physicians Group, P.A.

New Patient REGISTRATION FORM

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(Please Print)

Today’s date:

PCP:

PATIENT INFORMATION

Patient’s Last name:

First:

M. I.

Preferred Name

Date of Birth: &nbs= p; / &nbs= p; /

Sex: □ Male □ Female

Street address: &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; Apt. #

SS. No: &nbs= p; - &nbs= p; -

P.O. Box:

City:

State:

ZIP:

Home phone:

Preferred phone #: □ Home <= span style=3D'mso-spacerun:yes'> = 633; Mom ‘s cell □ Dad&#= 8217;s cell □ OK to leave message

Mother (Legal Guardian) Name:

Occupation:

Address (if different from above):

Cell phone:

Work phone:

E mail:

Father (Legal Guardian) Name:

Occupation:

Address (if different from above):

Cell phone:

Work phone:

E mail:

Referred by: Insurance<= span style=3D'mso-spacerun:yes'> Family Friend ___________________ Yellow pages= Physician __________= ________ Other

Other family members seen here:

INSURANCE INFORMATION

(Please give the insurance card and driver’s license to the receptionist.)

Person responsible for bill:

Home phone no.: ( )

Address (if different):

Birth date: &nbs= p; / &nbs= p; /

S.S. No.: &nbs= p; / &nbs= p; /

Occupation:

Employer:

Employer phone no.:

Employer address:

( )

Is this patient covered by insurance? q<= /span> Yes q<= /span> No

q Primary Insurance

Subscriber’s name: (if different from above)

Subscriber’s S.S. No.:

Birth date:

Subscriber ID/Policy #

Group #

Co Pay

/ /

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Patient’s relationship to subscriber:

q Self

q Spouse

q Child

q Other

Secondary insurance: □ Yes □<= span style=3D'mso-spacerun:yes'> No

Subscriber’s name: (if different from above)

Subscriber’s S.S. No.:

Birth date

Subscriber ID/Policy #

Group #

Co Pay

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Patient’s relationship to subscriber:

q Self

q Spouse

q Child

q Other

IN CASE OF EMERGENCY

Name of local friend or relative (not living at same address):

Relationship to patient:

Home phone no.:

Work phone no.:

( &nbs= p; )

The above information is true to the best of my kn= owledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Lone Star Physicians Group, P.A or insurance company to release a= ny information required to process my claims.

Preferred E-mail address (for our office communicati= ons only):

Parent/Guardian signature:

Date:

Parent/ Guardian Name (Print):