Patient Registration Form

"*" indicates required fields

Please complete all sections. The patient, if an adult is regarded as being responsible for all charges generated.
Date*
Patient Name*
Address*
Date of Birth*
Email*
Emergency contact*
Emergency contact address*

Insurance Information

Name of person responsible for account:*
Date of Birth*
Address (if different from above):
Name of Insured on Card*
Responsible party agrees to fill out new form when any of the above information changes. Wrong information may result in incorrect filing and subsequent charges.

Secondary Insurance

Assignment and Release

I, the undersigned, hereby authorize and direct my insurance carrier to pay directly to Inspire Care, PC all insurance benefits, if any, due to me under by insurance plan. I further agree to pay the balance of the charges not paid by my insurance. I hereby authorize the release of any information necessary to secure payment of benefits. I also authorize the use of this signature on all insurance submissions. If the patient is a minor, I as a legal guardian give consent for treatment for this and future services rendered. I have received the Notice of Privacy Practices and I have been provided an opportunity to review it. Responsible Person/Patient
Date*