New Patient Registration Form

If you are a new patient, please fill out the entire registration form, below. (If your child is the patient, be sure to put his or her name and information in the Patient Information section and not yours. Put your information in the Responsible Party section.)

Patient Information

Which Physicians Quality Care location will you go to for medical treatment? Jackson    Milan
Patient's First Name
Middle Name
Last Name
Address
City
State
Zip Code
Home Phone #
Cell Phone #
Best # to call
Email Address
Birth Date (dd/mm/yyyy)
Social Security #
Sex Male     Female
Family Physician

Responsible Party (or parent name if patient is a minor)

First Name
Last Name
Birth Date (dd/mm/yyyy)
Sex Male     Female
Address Check if same as patient
City
State
Zip Code

Emergency Contact Info

Name
Phone #

Insurance Information (Please give your insurance card to the receptionist.)

 I choose to pay for my visit myself at the time of service
Policy Holder First Name
Policy Holder Middle Name
Policy Holder Last Name
Birth Date (dd/mm/yyyy)
Policy Holder Sex Male     Female
Policy Holder SS#
Patient’s relationship
to subscriber
Self    Spouse    Child    Other
Address
City
State
Zip Code
Phone Number
Mobile Phone Number
Insurance Company
Insurance ID #
Group #
Address
City
State
Zip Code
   

Patient Employment Information

Employer
Employment
Retired 
Disabled
Student 
Self-employed 
Minor 
Unemployed

Employer Address
Employer City
Employer State
Employer Zip Code
Employer Phone #
Occupation
Title

Authorization for Release of Information to Another Party

I hereby authorize Physicians Quality Care to discuss financial and insurance information for myself or my minor child with:

Name
Relationship

I hereby acknowledge that 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 Physicians Quality Care or insurance company to release any information required to process my claims. I agree to pay all cost of collection including, but not limited to attorney fees, collection fees, and contingent fees to collection agencies not less than 35%. Such contingent fee will be added and collected by the collection agency immediately upon my default and office’s referral of my account to said collection agency.

Please type your initials

When you submit this form, you are agreeing to the conditions above and that the information you filled out is correct.