Patient Access Registration Form
Print clearly and complete the information on both sides of this form. Upon completion, sign and return with identification and insurance card.
Name
*
First Name
Middle Initial
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Preferred Name
Sex (as listed on insurance):
*
Male
Female
Other
Sexual Orientation:
*
Bisexual
Lesbian, gay, or homosexual
Straight or heterosexual
Choose not to disclose
Don't know
Other
Gender Identity:
*
Female
Female-to-Male/Transgender Male
Male
Male-to-Female/Transgender Female
Neither exclusively male nor female
Other
Pronouns:
He-Him
She-Her
They-Them
Other
Social Security
*
Email Address:
*
example@example.com
Home Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship Status:
*
Single
Married
Partnered
Divorced
Separated
Widowed
Race:
*
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Prefer Not to State
Other
Ethnicity:
*
Hispanic or Latino
Not Hispanic or Latino
Prefer Not to State
Religious Preference:
Preferred Language:
Does Patient have an Advanced Directive or Living Will?
Yes
No
Do you have a Primary Care Provider?
Yes
No
If yes, Primary Care Provider Name:
PCP Phone Number:
Format: (000) 000-0000.
PCP Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Emergency Contact Name 1:
Relationship to Patient:
Emergency Contact 1 - Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 1 - Address:
Emergency Contact Name 2:
Relationship to Patient:
Emergency Contact 2 - Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 2 - Address:
Employment Status:
Full-Time
Part-Time
Unemployed
Disabled
Occupation:
Name of Employer:
Address of Employer:
Phone Number of Employer:
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Health Insurance:
*
Subscriber Name:
*
Subscriber Date of Birth:
*
-
Month
-
Day
Year
Date
Patient Relationship To Subscriber:
*
Policy ID Number:
*
Group Number
*
Secondary Health Insurance:
Secondary Subscriber Name:
Patient Relationship To Subscriber:
Secondary Policy ID Number:
Secondary Group Number
I CONFIRM THAT ALL THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE.
Signature
*
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General Permission for Treatment
I allow
One Bergen Health, PC
to give me medical treatment.
I allow
One Bergen Health, PC
to perform:
Any indicated testing
Any laboratory tests
Any other medical care ordered by the Licensed Practitioners
An HIV test if necessary (I may refuse after speaking with a Licensed Practitioner)
I understand that:
One Bergen Health, PC
clinicians in training may help provide my care
under the superivsion of a licensed provider.
Other healthcare providers may need to participate in my care
Other healthcare providers may need to take pictures or recordings
There is no guaranteed results from treatment
This form may need to be filled out for every visit to a One Bergen Health, PC location
I have had the opportunity to review a copy of the NJ Patient/Resident Bill of Rights
I have had the opportunity to review a copy of the One Bergen Health, PC
Notice of Privacy Practices
I understand I can refuse any test, procedure or treatment
I allow
One Bergen Health, PC
to seek payment from my health insurance
for the care I received.
I understand that:
One Bergen Health, PC
will send my medical information to my health insurance company
I must pay my share of the costs
I must pay if I do not have insurance
I must pay if my insurance does not pay
SIGNED
Patient Name:
*
First Name
Last Name
Signature
*
Parent/Legal Guardian
First Name
Last Name
Relationship to Patient
Parent/Legal Guardian Signature
Witness:
TITLE
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Upload image of front of Photo ID
*
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Upload image of back of Photo ID
*
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Do you have insurance?
*
Yes
No
Upload image of front of insurance card
*
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Upload image of back of insurance card
*
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Is it safe for the LGBTQ+ Health & Wellness Center to communicate by phone and/or leave a voicemail?
*
Yes
No
Preferred method of communication:
phone, email, text
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