Patient Registration Form

Patient’s Information

Name:_____________________S.S.#:____-_____-______D.O.B.:________Sex:  M or F

Address:_________________________Phone#:(   )____________Marital Status:______

              _________________________Fax#:(   )____________Email:_______________

Employer:_____________________________Work:(   )__________________

Responsible Party’s Information

Name:_______________________D.O.B.:_____________S.S.#:______-_____-_______

Address:________________________Phone#(   )_____________Work#:(   )________________

              _________________________Employer:_____________________________________

Insurance Information

Primary                                   Secondary

Insurance:__________________________       Insurance:______________________

Member#:_____________Group#:_______     Member#:________________Group#:__________

Insured Party:_______________________       Insured Party:_______________________

D.O.B.:______Employer:______________     D.O.B.:_______Employer:_________________

Primary Insurance:  Circle Patient’s relation to Insured:   Self   Spouse   Child    Guardian

Please Read the Following and Sign Below

*I hereby request that payment of authorized insurance benefits be made on my behalf to Arnold Kirshenbaum, M.D., c/o Allergy Health Care.  In addition, I authorize Dr. Kirshenbaum, as holder of my medical records, to release to my insurance carrier any information necessary to determine benefits payable for these or other related services.

*I understand that I am financially responsible for any non-covered expense and /or balances of covered expenses including, but not limited to , co-pays and deductibles, which are due at the time of my visits.  I also understand that my account is subject to collections in the event that I do not take care of my responsibilities to the physician after proper notice, and that I am responsible for all collection fees and costs for the collection of my account, including attorneys’ fees. 

*All bills are due upon receipt.  In the event payments are not received within the 30 days, I understand the 1 ½ % per month carrying charge (18% APR) will be added.

*In addition, if I fail to come in for a scheduled appointment without giving 24-hour notice, I am subject to a fee of $100.00 for a new patient appointment and $50.00 for a follow-up appointment. 

_____________________________________(SEAL)          Date:___________________

  (Signature of Patient or Responsible Party)

 _____________________________________(SEAL)          Date:___________________

                             (Witness)