Adult Registration Form

Person responsible for bill
(Complete only if different from patient)
Guarantor Name:
Social Security Number:
Relationship to Patient:
- Self
- Spouse
- Parent
Date of Birth:
Month
Day
Year
Phone
Address
Street Address City State ZIP Code
First Insurance Information
Plan Name:
I.D. Number:
Group Number:
Address
Street Address City State ZIP Code
Policy Holder:
Effective Date:
MM slash DD slash YYYY
Policy Holder’s Social Security Number:
Policy Holder’s Date of Birth:
Month
Day
Year
Sex:
- M
- F
Second Insurance Information
Plan Name:
I.D. Number:
Group Number:
Address
Street Address City State ZIP Code
Policy Holder:
Effective Date:
MM slash DD slash YYYY
Policy Holder’s Social Security Number:
Policy Holder’s Date of Birth:
Month
Day
Year
Sex:
- M
- F

Who to call for an emergency:
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Work Phone
Relationship
MEDICATION HISTORY
CONSENT*
I authorize ENT Partners of Texas to obtain my medication history.
Initials*
Date
MM slash DD slash YYYY
ASSIGNMENT OF BENEFITS – RELEASE OF INFORMATION FOR BILLING
CONSENT*
I agree to the following:
I authorize treatment of the person named above and agree to pay all fees for such treatment. I also authorize the release of any medical information necessary to process these claims. I hereby authorize ENT Partners of Texas to receive all benefits to which I or my dependents are entitled to under my health insurance plan. I agree that I will not withhold or delay payment if my insurance company denies payment on any of my charges. The undersigned agrees that whether he/she signs as an agent that he/she is obligated to pay for the account.
Initials*
Date
MM slash DD slash YYYY
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
CONSENT*
I agree to the privacy practices.
We keep a record of the health care services we provide you. You may ask to see and copy that record. You may also ask to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your record or get more information about it by contacting our Medical Records Coordinator or Privacy Officer. My signature acknowledges my receipt of the Notice of Privacy Practices for ENT Partners of Texas.
Initials*
Date
MM slash DD slash YYYY
STUDENT OBSERVATION
- I give my permission for a student to be present with the physician during my visit.
- I decline permission for a student to be present with the physician during my visit.
I give my permission to have a student present with the physician during my appointment. Please check one of the options concerning your consent.
Initials*
Date
MM slash DD slash YYYY