Hamilton Psychiatric Services

Please complete the details below to submit your patient registration request.

First Name*

Last Name*

Middle Initial*

Age

Address*

Apartment No

Email *

Cell Phone

Home Phone

Other Phone

Driver License Number

Date of Birth

Sex

Male Female

Social Security Number

Martial Status

M S D W

Reason For Visit

Referring Doctor

Employer

Name

Address

Phone

Person Responsible For Payment

Name *

Last Name

Middle Initial

Address

Email *

Home Phone

Cell Phone

Fax

Other Phone

Driver License Number

Date of Birth

Sex

Male Female

Social Security Number

Martial Status

M S D W

Select Appropriate Box

Illness Auto Accident Work Related Others

Date of Accident

Primary Insurance

Name

Policy And Id Number

Relationship to Policy Holder

Self Spouse Child

Secondary Insurance

Name *

Policy And Id Number

Relationship to Policy Holder

Self Spouse Child

Emergency Contact

Name

Phone

Relationship

Child Father Mother G. Parent Spouse Friend

Address

Name

Phone

Relationship

Child Father Mother G. Parent Spouse Friend

Address

Note: INSURANCE POLICIES ARE CONTRACTS BETWEEN YOU, THE SUBSCRIBER, AND THE INSURANCE COMPANY.THE DOCTOR CAN IN NO WAY ALTER THE CONTRACT NOR GUARANTEE PAYMENTS BY THE INSURANCE COMPANY.IN CERTAIN INSTANCES, INSURANCE COMPANY MAY FORWARD PAYMENT DIRECTLY TO THE SUBSCRIBER FOROUR SERVICES. IT IS PATIENT RESPONSIBILITY TO BRING SUCH PAYMENT(s)TO THIS OFFICE. FAILURE TO BRINGPAYMENT TO THIS OFFICE MAY RESULT IN APPOINTMENT CANCELLATION AND FORWARD TO COLLECTION.I UNDERSTAND THAT THE BALANCE AND PAYMENT OF MY ACCOUNT ARE MY RESPONSIBILITIES.

I authorize the release of any medical or other information necessary to process the insurance claim. I also request payment of benefits to be send to party who accept assignment.

Patient Registration Form

Employer

Person Responsible For Payment

Primary Insurance

Secondary Insurance

Emergency Contact

Office

Time Sheduled

Address

Email