Calendar
Directions
Contact
Services
Physician Information
 
 
 
 
 
 
 
 

Mecklenburg Neurological Associates
Registration Form

Download Printable PDF Form
Date:  PCP    Referring MD
Last Name  First  Middle
DOB  Age Sex Male Female
Marital Status Single Married Partner Divorced Widowed
Street Address
City/St/Zip
SSN # Phone Cell  
Employer
Work Phone
Chose Clinic due to Dr Insurance Plan Hospital Plan 0 Other

Insurance Information
Person Responsible for bill DOB
Address if different from above
Employer
Phone
Please indicate Primary Insurance
Phone
Subscriber’s Name
  DOB SSN
Policy
Group #
Copay amt
Patient’s relationship to subscriber Self Spouse Child Other
Secondary Insurance (if applicable)
Subscriber’s Name
  DOB SSN
Phone
Policy
Group #
Patient’s relationship to subscriber Self Spouse Child Other

In case of Emergency
Name of friend or relative not at same address
Relationship to patient
Phone
The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Mecklenburg Neurological or the insurance company to release any information required to process my claims.
Signature/Guardian Signature     Date