FIRST NAME
LAST NAME
INITIAL
ADDRESS
CITY/STATE/ZIP
HOME PHONE #
WORK PHONE #
EMAIL ADDRESS
CELL PHONE #
MESSAGES ABOUT ACCOUNT BALANCES AND FUTURE APPOINTMENTS WILL BE LEFT ON THE CONTACT INFORMATION PROVIDED ABOVE
DATE OF BIRTH
GENDER
MALEFEMALE
MARITAL STATUS
SOCIAL SECURITY NUMBER
REFERRING DOCTOR
EMPLOYMENT (Check One)
FULL TIMEPART TIMESTUDENTNOT EMPLOYED
EMPLOYER
PHONE
INSURANCE INFORMATION
PRIMARY INSURANCE NAME
NAME OF POLICY HOLDER
RELATIONSHIP OF PATIENT TO THE INSURED
INS ADDRESS
INSURED’S ID #
GROUP #
EFFECTIVE DATES
IN CASE OF EMERGENCY, WHO SHOULD BE NOTIFIED?
PHONE #
WORKERS’ COMPENSATION/PERSONAL INJURY INFORMATION
ATTORNEY NAME
ATTORNEY PHONE
WERE YOU HURT AT WORK?
YN
DATE OF INJURY
HAVE YOU FILED A CLAIM?
WORKERS’ COMPENSATION CLAIM #
ADJUSTERS NAME
ADJUSTERS PHONE
ADJUSTERS ADDRESS
CITY, STATE, ZIP
Our staff is trained to inform you of the financial policies of this office.
Payment is due at the time of service. If payment is not paid at time of service, a $10 billing fee will be applied
Appointments for regular care that are not canceled at least 48 hours before the scheduled appointment during hours of operations are subject to a $40 “NO SHOW FEE”.
We accept payment in the form of cash, check and credit card (*).
I understand that I am financially responsible for all charges for services to me, including the balance remaining after payment of possible insurance benefits or non-payment.
In the event it is necessary to refer your account to an attorney for collections, you will be responsible for all charges accrued; i.e. attorney’s fees, court costs, expenses, etc.
* Check Writing Policy: No check will be honored without driver’s license. All returned checks are subjected to a return check fee of $40.
* CHARGEBACK CARD: Any card that a chargeback is initiated without the consent of South Coast Neurology, Inc is subject to a $40.00 fee, regardless of the balance as well as late fees that apply to an overdue balance. Primary Insurance and Plan Insurance Address should not be required to sign
I am aware that obtaining test results may require a face-to-face consult with a licensed medical professional. Some test results cannot be given over the phone, email and/or via facsimile. These regulations are in compliance with appropriate medical care guidelines and other government agencies within the of State of California. Initials
SIGNATURE OF PATIENT OR LEGAL GUARDIAN (SEAL)
DATE
The following forms can be printed out as a PDF:
Patient Registration Form [PDF]
