ABRONS FAMILY PRACTICE


 


910-790-7840

Forms
Patient Registration
Abrons Family Practice
1911 S. 17th St; Suite 130A
Wilmington, NC 28401
910.790.7840

 

Todays' Date:
Patient Last Name:
Patient First Name:
Mailing Address:
Physical Address (if different than above):
Date of Birth
Age:
Sex:
Marital Status:
Primary Phone:
Secondary Phone:
Patient's SSN:
Parent/Guardian's Name:
Guardian's SSN:
Relationship:
Primary Insurance:
Please fill in if your Insurance is not listed above:
ID Number:
Group Number:
Insured's Name:
Insured's SSN:
Secondary Insurance:
 
 

Special Permissions
Please let us know your perferences by answering the quesions below:

 

 

It is ok to leave test results on my voicemail

 

It is ok to discuss test reults with my family

 

It is ok to call me at work with test    results or appointments

 

It is ok to treat minor patient in my absence after the initial registration

 
Authorizations
Please indicate your acceptance of the following authorizations by checking the box
You may also be required to sign this form when you come in for your visit

 

 

I hereby give authorization for payment of insurance benefits to be made directly to Abrons Family Practice, and any assisting physicians or mid-level providers for services rendered. I understandthat I am financially responsible for all charges whether or not they are covered by my insurance. Further, I hereby authorize theis heatlthcare facility to release all information necessary to secure payments of benefits.

 

I do hereby give authorization to the medical staff of Abrons Family Practice to evaluate, treat, order labs and other diagnostic tests, and /or perform minor office procedures. I also accept full financial responsibility (regardless of insurance payment or non-payment) for all charges incurred by myself or any person(s) I am responsible for. Account balances must be cleared prior to another appointment being scheduled unless other prior arrangements have been made with the Office Manager.

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