New Patient Registration

Patient Information

Patient First Name

Please complete this field.

Patient Last Name

Please complete this field.

Chart #

Please complete this field.

Date of Birth

Please complete this field.

Social Security #

Please complete this field.

Gender

Please select an option.

Marital Status

Please complete this field.

Address

Please complete this field.

City

Please complete this field.

State

Please complete this field.

Zip

Please complete this field.

Home #

Please complete this field.

Cell #

Please complete this field.

Preferred #

Please select an option.

Consent to be texted

Employer

Please complete this field.

Work #

Please complete this field.

Ext

Please complete this field.

Email Address

Please complete this field.

Parent / Legal Guardian Information (if applicable)

(If there are any custodial issues pertaining to this child, you must provide a copy of the custodial agreement)

Name

Please complete this field.

Address

Please complete this field.

City

Please complete this field.

State

Please complete this field.

Zip

Please complete this field.

Cell #

Please complete this field.

Home #

Please complete this field.

Work #

Please complete this field.

Guarantor Information ( Financially Responsible Party )

Check if Patient is Guarantor

Name

Please complete this field.

SSN

Please complete this field.

DOB

Please complete this field.

Address

Please complete this field.

State/City/Zip

Please complete this field.

Cell #

Please complete this field.

Relation to Patient

Please complete this field.

Insurance Information (We must have a copy of Insurance card(s) in order to file )

Primary Insurance

Please complete this field.

Policy #

Please complete this field.

Insured Name

Please complete this field.

SS # of Insured

Please complete this field.

DOB

Please complete this field.

Secondary Insurance

Please complete this field.

Policy #

Please complete this field.

Insured Name

Please complete this field.

SS # of Insured

Please complete this field.

DOB

Please complete this field.

I hereby authorize a representative from Palmetto Allergy & Asthma to speak to the following person(s) regarding my medical care and appointment(s) (ie, mother, father, spouse, sibling)

Name

Please complete this field.

Relationship

Please complete this field.

Phone #

Please complete this field.

Name

Please complete this field.

Relationship

Please complete this field.

Phone #

Please complete this field.

I do NOT wish for any medical information / appointments to be released to any representative on my behalf

Emergency Contact

Name

Please complete this field.

Relation

Please complete this field.

Phone #

Please complete this field.

Allow Email and Text for Communication

Assignment of Insurance Benefits & HIPPA

(We must have your signature below in order to process insurance claims)

I hereby authorize the attending Physician to furnish from his records any information requested to any insurance company affording coverage to me or liable third parties in connection with the above assignment. In the event that the undersigned is entitled to Physician benefits, said benefits are hereby assigned to the Physician and paid directly to Palmetto Allergy & Asthma. If insurance benefits are not paid within 45 days of service, charges will be responsibility of the patient. I have received or have been offered a copy of Palmetto Allergy & Asthma's "Notice of Privacy Practices."

Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Date

Please complete this field.

Subscribe to updates from Lisa Hutto, MD

New Patient Registration

Patient Information

Patient Information

Parent / Legal Guardian Information (if applicable)

Parent / Legal Guardian Information (if applicable)

(**If there are any custodial issues pertaining to this child, you must provide a copy of the custodial agreement**)

Guarantor Information ( Financially Responsible Party )

Guarantor Information ( Financially Responsible Party )

Insurance Information (We must have a copy of Insurance card(s) in order to file )

Insurance Information (We must have a copy of Insurance card(s) in order to file )

Emergency Contact

Emergency Contact

Assignment of Insurance Benefits & HIPPA

Assignment of Insurance Benefits & HIPPA

(**We must have your signature below in order to process insurance claims**)

(If there are any custodial issues pertaining to this child, you must provide a copy of the custodial agreement)

(We must have your signature below in order to process insurance claims)