Patient Information

Family Care Clinic location you are registering for:

Patient Full Legal Name

First
Middle
Last
Address*
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Employer's Address
Marital Status
Sex

Emergency Contact

Insurance Information

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Additional Insurance

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Insured / Spouse / Parent

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Employer's Address
Would you like to enroll in our Patient Portal?
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.
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