New Patient Registration Form

Name (First, Middle, Last)
Street Address(required)
Street Address2
City(required)
State(required)
Zipcode(required)
Day Telephone #(required)
Evening Telephone #
Cell #
D.O.B.(required)
Sex(required)
Marital Status(required)
Employer Name(required)
Employer Address
Responsible/Insured Party (First, Middle, Last)(required)
Responsible/Insured Party Employer(required)
Responsible/Insured Party Employer Address
Responsible/Insured Party D.O.B.(required)
Relation to Patient(required)
Insurance Name(required)
Policy #(required)
Insurance Claims Address
Insurance Tel#(required)
I authorize treatment by Primary Plus Organic Medicine, LLC. I agree to be responsible for my bill. I authorize disclosure of my medical records to any agency involved in payment for my treatment. I also will be responsible for any reasonable collection or attorney fees incurred in the collection of any amount due to Primary Plus Organic Medicine, LLC.
I understand that my information isconfidential and that I have reviewed my HIPAA privacy statement to ensure the standards the practice uses to safeguard my records.