Patient Registration Form

PATIENT LAST NAME			FIRST NAME				MIDDLE INITIAL

PRIMARY STREET ADDRESS		CITY/TOWN				STATE	ZIP CODE

HOME TELEPHONE NUMBER	DATE OF BIRTH			GENDER	PATIENT SOCIAL SECURITY NUMBER
( ) -	/ /			M F	- -
CELL PHONE NUMBER	EMAIL ADDRESS
	@
EMPLOYER NAME	EMPLOYER PHONE NUMBER
	( ) -
EMPLOYER STREET ADDRESS		CITY/TOWN				STATE	ZIP CODE

EMERGENCY CONTACT NAME (not living at patient address)		PHONE NUMBER				RELATIONSHIP TO PATIENT
		( ) -
WHICH DOCTOR SENT YOU HERE TODAY?			LIST ANY OTHER DOCTOR(s) WHO SHOULD RECEIVE A REPORT

WHAT SERVICE ARE YOU HAVING DONE TODAY?			o MRI o CT o MAMMOGRAPHY o X-RAY o ULTRASOUND o FLUOROSCOPY o BONE DENSITY oOTHER:_____________
HAVE YOU EVER BEEN TO BERLAND PRIOR TO TODAY?			o YES o NO
HOW DID YOU HEAR ABOUT BERLAND?			o MY DOCTOR o FRIENDS/FAMILY o PHONE BOOK o BEEN HERE BEFORE o OTHER:_____________________

INSURANCE INFORMATION

PLEASE BE SURE TO BRING YOUR INSURANCE CARD(S) WITH YOU TO YOUR APPOINTMENT.

PRIMARY INSURANCE CARRIER NAME
INSURANCE MAILING ADDRESS			CITY/TOWN			STATE	ZIP CODE

POLICY #	GROUP #				EMPLOYER

POLICY HOLDER’S NAME		PT RELATIONSHIP TO POLICY HOLDER		POLICYHOLDER’S SOC SEC #
				- -

ASSIGNMENT OF BENEFITS / MEDICAL RELEASE: I authorize the release of any payment and medical information necessary to process this claim and related claims. I request payment of benefits to BERLAND DIAGNOSTIC IMAGING CENTER OF CREVE COEUR who accepts assignment of benefits. I understand that if my account is not paid when due, I will be responsible for all costs incurred in the collection process of my account. I further understand that any unpaid balance will be reported to a credit bureau.

________________________________________________________________ _____________________________________

Patient or Authorized Signature Date

HAVE YOU EVER BEEN TO BERLAND PRIOR TO TODAY?

INSURANCE INFORMATION

PRIMARY INSURANCE CARRIER NAME

POLICY HOLDER’S NAME