Vinod K. Rustgi, M.D., FACP, FACG
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: DATE OF BIRTH: SEX:
CELL PHONE: WORK PHONE: EXT.:
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:
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