Family Care Clinic Patient Information - Cullman Regional Medical Center

Patient Information

Family Care Clinic location you are registering for:

Family Care Clinic - Hospital, Professional Office Building 1
Family Care Clinic - Main Avenue SW

Patient Full Legal Name*

Address*

Mailing Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth

Occupation

Primary Physician

Employer's Name

Employer's Address

Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone #*

Secondary Phone #

Work Phone #

Patient Email

Marital Status

Social Security Number*

Driver's License Number

Driver's License State

Sex

Male
Female

Age

Emergency Contact

Contact's Full Name*

Contact's Primary Phone*

Relationship to Patient*

Insurance Information

Insurance Provider

Policy/Contract Number or Member ID

Group Number

Policy Effective Date

Policy Holder/Beneficiary

Date of Birth

Additional Insurance

Insurance Provider

Policy/Contract Number or Member ID

Group Number

Policy Effective Date

Policy Holder/Beneficiary

Date of Birth

Primary Care Physician with Insurance Carrier

Insured / Spouse / Parent

Name

Date of Birth

Social Security Number

Employer

Work Phone Number

Employer's Address

Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Would you like to enroll in our Patient Portal?

Yes
No

I hereby authorize CULLMAN REGIONAL FAMILY CARE CLINIC to furnish to the insurance company(s) on file or to a designated attorney, all information which said insurance company(s) or attorney may request. I hereby assign to CULLMAN REGIONAL FAMILY CARE CLINIC all money to which I am entitled for medical and/or surgical expense relative to the service rendered by him, but not to exceed my indebtedness to said physician and/or surgeon. It is understood that any money received from insurance company(s) on file, over and above my indebtedness will be refunded to me when my bill is paid in full. I understand I am financially responsible to said doctor(s) for charges not covered by this assignment. I further agree in the event of non-payment, to bear the cost of collection, and/or court cost and responsible legal fees should this be required. I understand that it is my responsibility to furnish current and correct personal and insurance information to CULLMAN REGIONAL FAMILY CARE CLINIC in a timely manner.

*

I agree to the terms above.

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