Patient Registration Form Lifespan Behavioral Health Services PC. Patient Registration FormName* First Middle Last Date of Birth* MM DD YYYY Gender*FemaleMaleTransgenderDeclinedMarital StatusSingleMarriedDivorcedWidowedAddress* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Preferred Phone Number* Home Cell HomeCellEmail* EthnicityHispanic or LatinoNot Hispanic or LatinoUnknown/DeclinedRaceAmerican Indian/Alaskan NativeAsianBlack/African AmericanNative Hawaiian/Pacific IslandWhiteOtherUnknown/DeclinedPreferred LanguageEnglishPreferred Communication for Appointment RemindersAppointment reminders are a courtesy service; all patients are responsible for remembering their scheduled appointments. We require a minimum of 24-hour notice for cancellations. Failure to do so may result in a charge for the missed appointment.Automated TextAutomated EmailGuarantor if not the patient (financially responsible party for minor or incapacitated adult)Guarantor Name First Last Date of Birth MM DD YYYY Relationship to PatientAddress Street Address City State / Province / Region ZIP / Postal Code Guarantor Preferred Phone Number Home Cell HomeCellEmailNote: By providing a phone number or email address, you are consenting to being contacted at that number or address regarding your treatment or billing information. In addition, your email will be used to invite you to join our secure patient portal. Please upload your state issued ID card.*Drivers License, Passport, Non-Drivers License Allowed file types include: jpg, png, pdf, gif, HEIC Maximum file size allowed: 25 MBAccepted file types: jpg, png, pdf, gif, heic.Please upload your insurance card.*Allowed file types include: jpg, png, pdf, gif, HEIC Maximum file size allowed: 25 MBAccepted file types: jpg, png, pdf, gif, heic.Emergency Contact Information & Relationship to PatientName First Last RelationshipEmergency Contact Phone*Insurance InformationPrimary Insurance Name*Address Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Zip Code Policy ID #*Group/Plan #*Co-Pay $Subscriber Name* First Last Subscriber Date of Birth* MM DD YYYY Subscriber Employer*Secondary Insurance NameAddress Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Zip Code Policy ID #Group/Plan #Co-Pay $Subscriber Name First Last Subscriber Date of Birth MM DD YYYY Subscriber EmployerClient SignatureDate MM DD YYYY Parent/Guardian SignatureFor minor First Last ConsentThe above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Lifespan Behavioral Health Services or my insurance company to release any information required to process my claims. I give my consent.EmailThis field is for validation purposes and should be left unchanged.
