Common Contracts
1 similar Patient Registration Agreement contracts
Morgan Chiropractic, Inc.Patient Registration Agreement • January 21st, 2022
PATIENT INFORMATION Patient Last Name: First Name: Middle Name: Marital Status (Select one)Other Date of Birth: Sex: SSN: Phone Number: Email Address: / / M / F Address: City: State: Zip Code: Employer: Job Title: Secondary Phone Number: INSURANCE INFORMATION Patient Car Insurance Company: Claim # Adjuster Name and Phone #: Other Party Insurance Company (if applicable) Claim # Adjuster Name and Phone #: Date of Accident: Date of Onset of Symptoms: AGREEMENT TO PAY ANY BALANCES In exchange for Morgan Chiropractic, Inc.’s forbearance from collecting all amounts owed by me for services rendered at the time of the provision of service, I hereby assign my rights to the clinic as follows: I understand and agree that health and accident insurance policies are an arrangement between an insurance company or carrier and myself. Furthermore, I understand that the clinic will prepare any necessary reports and forms provided by me to assist me, or my legal representative, in making collection from
