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PATIENT REGISTRATION Coastal ENT Medical Group PERSONAL Name ______________________________________________Date of Birth ____/_____/____ Age _______ M F Address _________________________________________________________________________________________ Phone_________________ Cell____________________ Fax ____________________ Email ____________________ City __________________________State ________ Zip _____________Social Security # _______________________ EMPLOYMENT Employer _________________________________________________Work Phone ( )______________________ Address___________________________________________________Occupation_____________________________ City______________________________________________________ State__________ Zip____________________ IN CASE OF EMERGENCY-Nearest Relative to contact. (Other than responsible party) Name__________________________________________________Relationship______________________________ Address_________________________________________________Phone ( )____________________________ PERSON RESPONSIBLE FOR PAYMENT Name________________________________Relationship___________Home Phone ( )____________________ Address _________________________________________________Business Phone ( )____________________ Employer ______________________________DOB ___/____/____Social Security # ___________________________ INSURANCE--Please present cards to receptionist PPO Medicare HMO Cash Other___________________________________ Primary Insurance Name___________________________________ Subscriber ______________________________ Secondary Insurance Name_________________________________ Subscriber ______________________________ REFERRAL - Who referred you to our office? __________________________________________________________ Yellow Page Insurance Book Physician Friend ScrippsHealth Internet Other______________________I give my permission for treatment by Drs. Halsey and Staff, and release of information to my insurance carrier. I give my permission for photography necessary for my treatment and care. I authorize my insurance carriers to pay benefits directly to Coastal ENT Medical Group. Payment is expected when services are rendered. Please read complete financial policy for further clarification. Signed_______________________________________________________________ Date _____/_____/______
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