C104 Pt Registration 05-20-10.xlsm

Patient Demographic Form
UNM MEDICAL GROUP, INC.
Patient
Registration
Form
Center for
Development
and
Disability
for Life
2300Center
Menaul
Blvd NE
4700 Jefferson NE, Suite 100
Albuquerque,
87107
New Mexico,
Mexico, 87109
Albuquerque,New
272-5280
272-3000 Fax: (505)
Phone: (505)
505-925-7464
505-925-4539
PATIENT INFORMATION
Patient's Name (Last, First, MI):_________________________________________________________DOB:__________________
Address:____________________________________________________ 3KRQHBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
City:________________________________
State:
Patient's SSN:_________________________________ Sex:
Patient's Marital Status:_________________
Zip:7ULEe:
M
F
Race/Ethnicity:____________________________
If Married, Name of Spouse:______________________________________
Patient's Employment Status:_____________________
Occupation:_____________________________________________
Employer Name:__________________________________________________
Employer Phone:
Employer Address:_________________________________________________________________________________________
PARENT / GUARDIAN (IF PATIENT IS A MINOR)
Name:______________________________________________________
Relationship:______________________________
Address:_________________________________________________________________________________________________
City:________________________________
State:
Zip:
Phone:
NEXT OF KIN / EMERGENCY CONTACT INFORMATION
Next of Kin:__________________________________________________
Relationship:______________________________
Address:_________________________________________________________________________________________________
State:
City:________________________________
Zip:
Phone:
REFERRING PHYSICIAN
Physician Name:______________________________________________
Phone/Fax:_______________________________
Address:_________________________________________________________________________________________________
INSURANCE INFORMATION
Is patient covered under Medicare/Medicaid? (please circle )Yes / No
If covered under Medicaid, which salud? (please circle)
lease ci
Medicare/Medicaid #:_____________________________
Molina / BCBS / Lovelace / Presbyterian
Is patient covered under Insurance? (please circle) Yes / No
(Please circle)
yes, please provide the following:
If yes, please provide theIffollowing:
Policy holder's Name: _____________________________________________ Policy holder's DOB:_________________________
Policy holder's SSN:_________________________________
Relationship to Patient:_________________________________
Insurance Company:__________________________________________
Phone:___________________________________
Address:_________________________________________________________________________________________________
Group #:___________________ Policy #:_________________________
Policy holder's Employer:___________________________________________
Authorization #:____________________________
Occupation:_______________________________
Employer Address:_________________________________________________________________________________________
City:________________________________ State:________
Zip:__________Telephone:________________________________
Authorization
I hereby authorize CDD or UNM Medical Group, Inc. to release any information acquired in the course of my evaluation to the insurance company. I
understand I have the right to examine and copy the information disclosed. I authorize payment directly to CDD or UNM Medical Group, Inc. for the
medical benefits.
Signature:________________________________________________________________________ Date:_________________
CDD 06/04/12
Patient Demographic Form
UNM MEDICAL GROUP, INC.
Registration
Form
CenterPatient
for Development
and
Disability
forBlvd
LifeNE
2300Center
Menaul
4700 Jefferson NE, Suite 100
Albuquerque, New Mexico, 87107
Albuquerque, New Mexico, 87109
272-3000 Fax: (505)
272-5280
Phone: (505)
505-925-7464
505-925-4539
Información de Paciente:
Nombre de Paciente:_________________________________________
Fecha de Nacimiento:_____________________
Direccion:___________________________________________________ Preferencia Religiosa:__________________________
Ciudad:_____________________________
Estado:
Código Postal:__________ Telefono:
Seguro Social de Paciente:____________________________ Sexo: M
Lugar de Nacimiento:______________________
F
Estado Civil:__________________________________ Nombre de Esposo(a):________________________________________
Estado de empleo del paciente:________________________ Ocupacion:____________________________________________
Patrón de Paciente:________________________________________________ Telefono del Patrón:
Direccion del Patrón:_______________________________________________________________________________________
PADRE / GUARDA (Si El Paciente es un Menor de Edad)
Nombre de Padre/Guarda:___________________________________________ Relación:________________________________
Direccion: __________________________________________________________________________________________________
Ciudad:_____________________________ Estado:_______ Código Postal:__________ Telefono:
Información de Contacto para Emergencia/Familia:
Nombre:________________________________________________________
Relación:________________________________
Direccion: ________________________________________________________________________________________________
Ciudad:_____________________________ Estado:_______ Código Postal:__________ Telefono:
REFERRING
PHYSICIAN
REFERRING
PHYSICIAN
Nombre del Medico:___________________________________________
Telefono:_________________________________
Direccion: ________________________________________________________________________________________________
Información de Aseguranza:
¿Tiene el paciente Medicare y/o Medicaid? SRUIDYRUFtUFXOR Sí / No
Si está cubierto por Medicare, que Salud? por favor círculo
Esta asegurado(a)? SRUIDYRUFtUFXOR Sí / No
Número de Medicare/Medicaid: _______________________
Molina / BCBS / Lovelace / Presbyterian
Por favor proveer la siguiente información:
Nombre del Asegurado(a):______________________________________
Fecha de Nacimiento:_______________________
Número de Social Asegurado(a):_________________________________
Relación del Paciente:_______________________
Nombre de Aseguranza:_______________________________________
Número de Telefono:_______________________
Direccion:________________________________________________________________________________________________
Grupo #:__________________
Poliza de Seguro #:_____________________ Autorización#:____________________________
Nombre de Patrón:____________________________________________
OccUNMMGcion:_________________________
Dirección del Patrón:_______________________________________________________________________________________
Ciudad:_____________________________ Estado:_______ Código Postal:__________ Telefono del Patron:______________
Autorización
Estoy autorizando a CDD o University Physicians Associates (UNMMG) para divulgar la información obtenida en el transcurso de mi
evaluación necesaria para asuntos de aseguranza. Comprendo que también tengo derecho a examinar y obtener una copia de
la información divulgada.
Firma:______________________________________________________________
CDD 06/04/12
Fecha:__________________________