Family Chiropractic Clinic of Hillsborough NEW PATIENT REGISTRATION FORM
303 Omni Dr. Hillsborough, NJ 08844 908-359-0123-p 908-359-0143-fax, or email the
| (Please Print)Date:______________________ | Cell #___________________________ |
Patient’s Name | H # |
Address | |
Birth Date & Age | Fax # |
Marital Status: (circle one) S---M---W---D | SS # |
| Email | Website |
| Employed By: | Occupation |
Address | Work # & Ext |
Spouse/Parents Name: | Home # |
Birth Date & Age | SS # |
Address | |
Employed by | Occupation |
Address | W # & Ext |
| |
| |
Please Read: Payment is due at the time of service. Please supply all pertinent information
regarding your insurance coverage. If you have coverage by more than one carrier, please
supply both. You are responsible to know what your insurance covers.
Insurance Carrier One________________ | Insurance Carrier Two_________________ |
Type of Ins: Health / Auto / WC / other PIP | Type of Ins: Health / Auto / WC / other PIP |
Name of Ins. Co. | Name of Ins. Co. |
| Whose name is policy under | Whose name is policy under |
Policy Holder:---Self---Spouse--Parent | Policy Holder:---Self---Spouse--Parent |
Please give your insurance card and driver’s license to the staff to copy. If you want your ins.
verified before you come in please fill out the next section and get this paperwork to us or call
us with this info
| Policy or ID# | Policy or ID # |
Group # | Group # |
Effective Date | Effective Date |
| Verification Telephone # | Verification Telephone # |
In order to submit a claim from payment to us for services covered under your policy, we must have your authorization to release medical information to your insurance carrier.
I herby authorize The Family Chiropractic Clinic of Hillsborough to furnish information to insurance carriers concerning my illness and treatments. I also assign to the physician(s) all payments for services rendered. Any checks I receive from the insurance company for unpaid services provided at the Family Chiropractic Clinic of Hillsborough will be turned over to the Family Chiropractic Clinic of Hillsborough as soon as possible with all the paperwork. I understand that I am financially responsible for any balance not covered by this authorization, which amounts are due and payable at the time of treatment. I further understand and agree that I will be personally liable for any and all amounts unpaid by my insurance carrier within six months following treatment and, if not paid by me upon demand, for the costs of collection, including, but not limited to attorney fees and cost of suit. Upon any unpaid balance after the six- month period expires, interest will accrue at the rate of 1 ½ % per month.
Signature:
Date:
Forms/patientregistrationform/c/8/07