Patient Registration Form

Provider (select one):
Dr. DudleyDr. Shepard

Name:

DOB:

Address:

City/Zip:

Preferred Phone:

Alternative Phone:

Email:

Employer:

Employer Phone #:

Name:

DOB:

Address:

City/Zip:

Preferred Phone:

Alternative Phone:

Email:

Employer:

Employer Phone #:

We welcome you to plase sign up for "MY KID'S CHART", our patient portal, where you can securely communictae with doctors and staff, view and print your child's medical record? We will e-mail you the link so you can sign up.

Please Provide E-mail:

Preferred Pharmacy Name:

Pharmacy Phone:

Primary Insurance Policy Name:

Policy holder's Name:

Date of Birth:

Policy holder's Employer:

Insurance holder's Address(if different from above):

Primary Insurance Policy #:

Group #:

Insurance Address:

Phone #:

Any Secondary Insurance? If yes, Plan & Policy #:

I authorize the doctor to release any medical information including diagnosis, x-rays, test results, reports, and records pertaining to any treatment or examination rendered to me. I understand that this medical information may be used to any of the following purposes: Diagnostic, insurance, legal and at times when the Doctor deems it necessary in order to ensure the best medical care on my behalf.

I further understand that any person(s) that receive these medical recordsa will not release any of the medical information obtained by this authorization to any other person or organization without a further authorization signed by me for release of the information.

I authorize the release of any medical information necessary to process and claim. I permit a copy of the authorization to be used in place of original. This authorization may be revoked by either me or my insurance at any time in writing.

Your physician has remote access to the electronic medical record of the NCH Healthcare System and can view any testing or treatments provided to you at an NCH facility. Your permission is required to allow your physician remote access to your medical records.

Insurance Policy:
Insurance provides for your reimbursement on allowed medical charges. We will be happy to submit to most insurance carriers, if you have provided us with policy numbers, address, place of employment and any other patient information.

I have read the above and accept financial responsibility in full for this account.

Signature

Date