Patient Registration Agreement Sample Contracts
CHILD AND ADOESCENT PATIENT REGISTRATION AGREEMENTPatient Registration Agreement • October 6th, 2021
• I/We understand that the initial meeting is for the purpose of evaluation and to determine if a working relationship with Dr. Segal can be established.
Standard Contracts
PATIENT REGISTRATION AGREEMENT (ADULT)Patient Registration Agreement • July 10th, 2022
• I/We understand that the initial meeting is for the purpose of evaluation and to determine if a working relationship with Dr. Segal can be established.
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
The John Hampden Surgery AgreementPatient Registration Agreement • March 9th, 2016
Thank you for your request to join The John Hampden Surgery. Please note that all new patients are asked to provide proof of identification (children registering with their family do not have to do this). Please supply identification when returning your registration forms:
PATIENT REGISTRATION AGREEMENTPatient Registration Agreement • November 13th, 2017 • Pennsylvania
Please read the following Washington Health System Patient Registration Agreement (“Registration Agreement”) carefully before deciding whether to register for access to the non-public portions of this Washington Health System website ("Portal") or register use of the Washington Health System mobile app (“App”), which are both provided to you by Washington Health System (“WHS” or “we”) for the benefit of the Participating Providers (each, a “Provider”). The Portal and App are collectively referred to below as the “Platform”. This Platform will permit you to request and access certain telemedicine services and consultations (“Services”) as provided by the Providers, together with your identifiable health information whether submitted by you or generated as a result of your use of the Services ("Health Information").
PATIENT REGISTRATIONPatient Registration Agreement • August 2nd, 2020
PATIENT REGISTRATIONPatient Registration Agreement • February 18th, 2021
WELLSPAN ONLINE URGENTCARE―PATIENT REGISTRATION AGREEMENTPatient Registration Agreement • September 5th, 2017 • Pennsylvania
Please read the following WellSpan Health Patient Registration Agreement (“Agreement”) carefully before deciding whether to register for access to the non-public portions of this WellSpan Health website ("Portal") or register use of the WellSpan Health mobile app (“App”), which are both provided to you by WellSpan Health (“COMPANY”) for the benefit of WellSpan Medical Group Providers (each, a “Provider”). The Portal and App are collectively referred to below as the “Platform”. This Platform will permit you to request and access certain behavioral health and other medical consultation services (“Services”) as provided by the Providers, together with your identifiable health information whether submitted by you or generated as a result of your use of the Services ("Health Information").
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
Copley Health Alliance PATIENT REGISTRATIONPatient Registration Agreement • May 8th, 2014
and assign directly to Dr. ____________________ all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions.
Patient Registration AgreementPatient Registration Agreement • February 20th, 2018