New Patient Registration — Primary Health Clinics of Mississippi

Patient Information

Full Legal Name (Last, First, Middle)

Date of Birth (MM/DD/YYYY)

Sex at Birth

Male Female

Preferred Pronouns

Social Security Number (optional)

Home Address (Street)

City

State

ZIP Code

Primary Phone

Secondary Phone

Email Address

Preferred Language

Race / Ethnicity (optional)

Marital Status

Single Married Divorced Widowed Other

Employer / Occupation

How did you hear about us?

Referral from doctor Friend / Family Google / Internet Facebook Insurance directory Other: _______________

Emergency Contact

Emergency Contact Name

Relationship

Phone Number

Insurance Information

Primary Insurance Company

Member ID / Policy Number

Group Number

Insurance Phone Number

Policy Holder Name (if different from patient)

Policy Holder DOB

Relationship to Patient

Secondary Insurance Company (if applicable)

Secondary Member ID / Policy Number

Please bring your insurance card(s) to your appointment. A copy will be made for your file.

Preferred Clinic Location

Newton — 191 Northside Dr, Newton MS 39345 Meridian — 1727 6th Street, Meridian MS 39301 No preference

Consent to Treat & Assignment of Benefits

I authorize Primary Health Clinics of Mississippi and its providers to render medical treatment and diagnostic services deemed necessary for my care. I authorize the release of any medical information necessary to process insurance claims and assign benefits payable to the clinic. I understand that I am financially responsible for all charges not covered by my insurance, including co-pays, deductibles, and non-covered services. I acknowledge that I have received a copy of the HIPAA Privacy Notice.

Patient / Guardian Signature

Date

Printed Name

Relationship to Patient (if guardian)