Chart Number

First Name

Last Name

Middle Name

Name Preferred

Gender

Race

Ethnicity

Language

Social Security No.

Date of Birth

Age

Home Address

City

State

Zip

Email Address

Primary Care Doctor

Financial Responsibility

Referring Doctor

Patient's Home Phone

Patient's Work Phone

Patient's Cell Phone

Preferred Notification

Is the patient currently employed?

Yes No

Patient's Employer

Employer's Address

City

State

Zip

Patient's Marital Status

Spouse Name

Person we may contact in case of an emergency

Relationship

Name

Telephone

Address

City

State

Zip

INSURANCE INFORMATION - We cannot file your insurance without complete information and a copy of your insurance cards. Please bring your insurance card with you to the front desk when you have completed this form.

PRIMARY INSURANCE COVERAGE

Insurance Company

Address

Subscriber's Name

Subscriber's Sex

Subscriber's Date of Birth

Subscriber's Social Security #

Subscriber's Relationship

Subscriber's Employer

Subscriber's ID #

Subscriber's Group #

SECONDARY INSURANCE COVERAGE

Insurance Company

Address

Subscriber Name

Subscriber Sex

Subscriber's Date of Birth

Subscriber's Social Security #

Subscriber's Relationship

Subscriber's Employer

Subscriber's ID #

Subscriber's Group #

OTHER INSURANCE

Yes No

FINANCIAL AGREEMENTS AND AUTHORIZATION FOR TREATMENT: I hereby authorize Raleigh Medical Group, Cary Medical Group, Raleigh Adult Medicine, Wake Endoscopy Center and Wake Forest Endoscopy Center (“RMG/CMG/RAM/WEC/WF ENDO") and its physicians and such assistants as a physician may designate to furnish and perform on me or the patient stated above ("Patient") such medical care, examination and treatment as may be ordered by an RMG/CMG/RAM/VEC/WF ENDO physician in his or her medical judgment and such medical care, examination or treatment as is reasonable incident thereto. I hereby authorize direct payment to RMG/CMG/RAM/WEC/WF ENDO of all medical insurance benefits (including without limitation Medicare and Medicaid benefits) to which the Patient is entitled in consideration of services to be rendered by RMG/CMG/RAM/WEC/WF ENDO to the Patient. I understand that, to the extent permitted by applicable law, I am, and I agree hereby to be, financially responsible to RMG/CMG/RAM/WEC/WF ENDO for charges not covered by this agreement, and I hereby guarantee payment to RMG/CMG/RAM/WEC/WF ENDO on demand for all such charges.

Signature

Date

Treatment - Type

AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize RMG/CMG/RAM/WEC/WF ENDO to furnish, to the extent permitted by applicable law, any medical information acquired in the course of the Patient's examination and/or treatment to any insurance company, government agencies and their agents, and professional review organizations with which the Patient may have insurance coverage or which may be assisting in payment of the medical care provided by RMG/CMG/RAM/WEC/WF ENDO to the Patient. I also hereby authorize RMG/CMG/RAM/WEC/WF ENDO to release any medical information to any licensed physician, health care provider, or medical facility to which the Patient may be referred, admitted or transferred for further medical care. I understand that I may revoke this authorization by written notice at any time except to the extent that action already has been taken.

Signature

Date

Information - Type

Patient Registration

Person we may contact in case of an emergency

PRIMARY INSURANCE COVERAGE

SECONDARY INSURANCE COVERAGE

OTHER INSURANCE