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New Patient Registration

Home > New Patient Registration

1 Patient Information

2 Responsible Party Information

3 Primary Insurance Information

4 Secondary Insurance Information

PATIENT INFORMATION
Patient's Name
First Last
Physical Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Work Phone
Cell Phone
Gender
- Male
- Female
Social Security Number
Note: You may alternatively provide this information on your first visit.
Date of Birth
Date Format: MM slash DD slash YYYY

Primary Insurance Information
(Provide your insurance card to the front desk at check in)
Name of Insured
First Last
Patient Relationship to Insured
Insurance Company
Insurance Company Phone Number
Subscriber ID (Policy Number)
Group ID
Effective Date
Date Format: MM slash DD slash YYYY
Termination Date
Date Format: MM slash DD slash YYYY
Insured Date of Birth
Date Format: MM slash DD slash YYYY
Insured Social Security Number
Note: You may alternatively provide this information on your first visit.
Insured Employer
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insurance Company Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Secondary Insurance Information
Name of Insured
First Last
Patient Relationship to Insured
Insurance Company
Insurance Company Phone Number
Subscriber ID (Policy Number)
Group ID
Effective Date
Date Format: MM slash DD slash YYYY
Termination Date
Date Format: MM slash DD slash YYYY
Insured Date of Birth
Date Format: MM slash DD slash YYYY
Insured Social Security Number
Note: You may alternatively provide this information on your first visit.
Insured Employer
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insurance Company Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
I agree that the information supplied on this form is accurate and up-to-date to the best of my knowledge. I authorize the release of any information requested by my insurance carrier(s) that is necessary to process unpaid claims and also authorize payment "assigned" insurance benefits to The Doctors Luce Pediatrics, LLC
Patient (or Responsive Party) Signature
Date
Date Format: MM slash DD slash YYYY
Electronic Approval
- Use my name here as a digital signature