Vinod K. Rustgi, M.D., FACP, FACG

 
Patient Registration
 
Medical History
   (Please fillout the Medical History Form also.)
 Metropolitan Liver Diseases/Gastroenterology Center
E-mail: Office@metrohepgi.com
 
Patient Registration Form
LAST NAME FIRST NAME MIDDLE NAME
ADDRESS: E-MAIL ADDRESS:
CITY: STATE: ZIP:  
HOME PHONE: CELL PHONE: WORK PHONE: Ext.:
DATE OF BIRTH: SEX:
MARITAL STATUS: REFERRED BY:  
 
SSN: EMPLOYER:  
 
EMPLOYER ADDRESS:  
   
CITY: STATE: ZIP:  
 
PATIENT’S OCCUPATION:    
     
INSURANCE SUBSCRIBER
 
LAST NAME FIRST NAME & INITIAL RELATIONSHIP:
ADDRESS:  
 
CITY: STATE: ZIP:  
PHONE: RESPONSIBLE PARTY SSN: DATE OF BIRTH:
EMPLOYER OF INSURANCE HOLDER:
 WORK PHONE:
 

PRIMARY INSURANCE COMPANY (#1): HOW LONG?
ADDRESS: PHONE:
POLICY HOLDER
(Last name, First name): 		RELATIONSHIP:
 
CERTIFICATE NO. GROUP NO.
 
SECONDARY INSURANCE CARRIER (#2):
 HOW LONG?
 
ADDRESS:   PHONE:
 
POLICY HOLDER
(Last name, First name):		 RELATIONSHIP:
 
CERTIFICATE NO.   GROUP NO.
 

SPOUSE’S NAME: SPOUSE’S WORK
PHONE:
NEAREST LIVING
RELATIVE OR FRIEND NOT
LIVING WITH YOU:
 RELATIVE’S/FRIEND’S
PHONE:

WAIVER: AUTHORIZATION TO PAY BENEFITS TO PHYSICIAN:

I, , agree to be seen by , M.D. on . I acknowledge that I did not bring a referral as required by my insurance company or do not have any insurance card. I am electing to be seen today and agree to pay today for services rendered since I do not have a valid referral or insurance card.

________________ ______
Signed Date

 

I hereby authorize payment directly to the Physician of the Surgical and/or Medical Benefits, if any, otherwise payable to me for his services as described, realizing I am responsible to pay non-covered services. I also realize that I am responsible for any other costs incurred while collecting my outstanding balance(s).

AUTHORIZATION TO RELEASE INFORMATION:

I hereby authorize the Physician to release any information acquired in the course of my treatment necessary to process insurance claims.

________________ ______
Signed (Patient or Parent, if minor) Date