Patient Registration Form

Dalip K. Khurana, MD, PLLC

Date Today: _________________Patient’s Date of Birth:____________________
Last Name: _________________First Name: ______________________MI:___
Address:________________________________________________________
Phone: Home: _____________Cell: ______________ Work: ________________
Marital Status: Single ____Married ____Divorced _____Separated ____Widow____
Social Security Number: _______________Employer: ______________________
Primary Insurance: _________________Insurance ID #: ___________________
Insurance Group Number: ____________Co-Pay/ Deductible: ________________
Who holds/ Subscribes to Insurance: Name: Last __________First: _____________
Address of Subscriber: ______________________________________________
Date of Birth of Subscriber: __________Subscriber’s Soc Sec#: ________________
Phone: (Home) _____________ (Work) _____________ (Cell) ______________
Relationship: Self_______ Spouse_______ Parent _______Other______________
Other Insurance: ________________Insurance ID #: ______________________
Insurance Group Number: ____________Co-Pay/ Deductible: ________________
Who holds other Insurance: Name: Last ____________First: _________________
Address of Subscriber: ______________________________________________
Date of Birth of Subscriber: __________Subscriber’s Soc Sec#: ________________
Phone: (Home) _____________ (Work) _____________ (Cell) ______________
Relationship: Self______ Spouse______ Parent _______Other________________
Primary Care Physician: __________________________ Phone: _____________
Emergency Contact: _____________________________ Phone: _____________
Referred by: __________________________________ Phone: _____________

AUTHORIZATION TO RELEASE INFORMATION: I/We hereby authorize Dalip K. Khurana, MD, PLLC to release any medical or incidental information that may be necessary for medical benefits or in processing application for financial benefit. This includes but is not limited to my insurance company, Rehabilitation Services, Social Security administration and Worker’s Compensation.
Consent for Treatment: I/We hereby authorize Dalip K. Khurana, MD, PLLC to administer diagnostic and medical procedures as may be necessary for proper health.
Office Policy for Payment: I understand that I am responsible for payment of all charges. As a courtesy, my insurance will be billed for me. It is my responsibility to pay any deductible, co-pay or any other balance not paid for by my insurance company. I authorize benefits to be paid directly to the provider.

SIGNATURE_________________________________________Date_________
Patient (over 18 years) or responsible party.