Registration Form

Patient Registration Form
Date

MonthDayYear
Date
Child's Last Name
Child's First Name
Address

Address

Street Address Line 2

CityState

Zip
Sex
Child's Date of Birth

MonthDayYear
Date
Phone Numbers: Home
Cell
Email
example@example.com
Emergency contact (not living with you):
Last Name
First Name
Relationship to Patient
Phone
Alt
PRIMARY INSURANCE INFORMATION
Person responsible for account:
Last
First
Relationship to Patient
Date of Birth

MonthDayYear
Date
S.S #
Insurance Company
Contact #
Subscriber (ID) #
Group#
SECONDARY INSURANCE INFORMATION
Person responsible for account:
Last
First
Relationship to Patient
Date of Birth

MonthDayYear
Date
S.S #
Insurance Company
Contact #
Subscriber (ID) #
Group#
I, the undersigned, hereby authorize and direct my insurance carrier to pay directly to Applied Behavior Center for Autism/ABA Programming, INC all insurance benefits, if any, due to me under by insurance plan. I further agree to pay the balance of the charges not paid by my insurance. I hereby authorize the release of any information necessary to secure payment of benefits. I also authorize the use of this signature on all insurance submissions. If the patient is a minor, I as a legal guardian give consent for treatment for this and future services rendered. I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.
Parent/ Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Patient Registration Form