Patient
 Patient Registration Form 
(*) Marked Fields Are Required     
* Patient's Name:
* Sex: * Age:   * Birth Date:
M   F  
Marital Status:
Single Married Widowed Divorced
* Patient's Social Security :
* Residence Address:    
   
* City:   * State:   * Zip:
   
* Home Phone:   Office Phone:   * Cell Phone:
   
* Person Financially Responsible For This Account:
* Pl. Select Below:
Self Spouse
* Responsible Party's Birthdate:   * Responsible Party's Social Security:
 
* Responsible Party Drivers License: * State: * Number:
*Occupation: How Long at Current Employer?
Name of employer:   Address: Business Phone:
 
* Reason for Visit:
 * Referred by: (include address and phone)
* Person to contact in case of emergency:
 *Relationship to patient:
* Phone:
* Medicare:
Yes No
If yes Medicare Number:
* Medicaid:
Yes No
If yes Medicaid Number

* Effective Date:
* Medicare Secondary insurance name:
 * Address:
* Policy:
 * Group :
* Workers' Compensation?
Yes No

If Yes-put W/C or MVA carrier below:
 * Motor Vehicle?
Yes No
* Date of Accident:
 * Treatment authorized by:
* Claim:
 * W/C or MVA Insurance Phone:
* Primary insurance company:


* Address:
 * Is insurance through your employer?
Yes No
* Subscriber Name:


* Subscriber birth date:

* Policy:


* Group:
* Secondary Insurance Name:


* Address:
 * Policy:


* Group:
Lifetime Assignment of Benefits / Information Release / Authorization to Treat:

I authorize payment of medical benefits to Sunvalley Pain and Sleep Center for any services furnished. I understand that I am financially responsible for any amount not covered by my insurance carrier.

I authorize you to release to my insurance company or its agent information concerning health care, advice, treatment or supplies provided to me. This information will be used for the purpose of evaluating and administering claims of benefits.I also authorize the interdisciplinary team to perform the treatments or procedures approved by my referring physician.
I acknowledge that no guarantees, either expressed or implied, have been made to me regarding the outcome of any treatments and/or procedures. I fully understand that it is impossible to make any guarantees regarding the outcome of any medical treatment or procedure.I have received a copy of my Patient Rights and Responsibilities and this facility’s Grievance Procedure.

I declare that all statements made in this application are true, complete and correct to the best of my knowledge