Manet Community Health Center

Registration Form


Manet Community Health Center

Select one:


Patient Information

First Name:  

Last Name:

Middle Initial:

Date of Birth:

Birthplace:  

 

ADDRESS:

Street:  

Apartment #:  

City:  

State:  

Zip:  

Home Phone:  

Cell Phone:  

Work Phone:  

Social Security #:  

Please check if you are: Please check if you are:

Occupation:  

Employer:  

Are you head of household?

 

Number of Dependents:  

Primary Language:  

Secondary Language:  

Marital Status:

 

Race/Ethnicity:

 

Insurance Information

Do you have insurance? 

 

Please select the patient's relationship to Insurance Card Holder:

 

SUBSCRIBER:

Name of person who gets this insurance:  

Subscriber's date of birth:

Subscriber's telephone #:  

 

INSURANCE PLAN:

Name of Insurance Plan:  

Doctor or Health Center Name listed on your card:  

ID number:  

Group Number:  

Group Name:  

 

SECOND INSURANCE PLAN:

Please select the patient's relationship to Insurance Card Holder:

Name of person who gets this insurance:  

Name of Insurance Plan:  

ID number:  

Group Number:  

Group Name:  

 

Emergency and Authorization Information

If patient is a child:

Parent/Guardian's Name:  

Billing Address (if different from above address):  

PERSON YOU WANT CALLED IN AN EMERGENCY:

Name:  

Relationship:  

Address:  

Work Phone:  

Home Phone:  

Cell Phone:  

I hereby authorize the staff of Manet Community Health Center, Inc., to render such services as deemed necessary to me/my child listed above. I also authorize the release of all necessary information to insurance companies and other payers and assign to Manet Community Health Center, Inc. the authority to claim and collect insurance benefits. I will be financially responsible for any charges incurred for services not covered by my insurance plan. I acknowledge that I have received notice that I may receive a copy of Manet Community Health Center's Patients Privacy Rights and the Privacy Policies and Practices upon request.

Check if:

Indicate relationship if 'other':  

Leave this empty:

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Manet Community Health Center https://www.manetchc.org
Signature Certificate
Document name: Registration Form
lock iconUnique Document ID: cdf6461b5eda6385a7c243c45c28f44139b47cf2
Timestamp Audit
June 13, 2020 12:32 pm ESTRegistration Form Uploaded by Stefanie Curry - stefaniecurry@comcast.net IP 73.227.241.65
June 15, 2020 1:41 pm ESTSandra McGunigle - smcgunigle@manetchc.org added by Stefanie Curry - stefaniecurry15@gmail.com as a CC'd Recipient Ip: 73.227.241.65
June 15, 2020 1:43 pm ESTSandra McGunigle - smcgunigle@manetchc.org added by Stefanie Curry - stefaniecurry15@gmail.com as a CC'd Recipient Ip: 73.227.241.65
June 15, 2020 1:47 pm ESTSandra McGunigle - smcgunigle@manetchc.org added by Stefanie Curry - stefaniecurry15@gmail.com as a CC'd Recipient Ip: 73.227.241.65
June 15, 2020 1:52 pm ESTSandra McGunigle - smcgunigle@manetchc.org added by Stefanie Curry - stefaniecurry15@gmail.com as a CC'd Recipient Ip: 73.227.241.65
June 15, 2020 1:55 pm ESTSandra McGunigle - smcgunigle@manetchc.org added by Stefanie Curry - stefaniecurry15@gmail.com as a CC'd Recipient Ip: 73.227.241.65
June 15, 2020 2:04 pm ESTSandra McGunigle - smcgunigle@manetchc.org added by Stefanie Curry - stefaniecurry@comcast.net as a CC'd Recipient Ip: 73.227.241.65
June 17, 2020 12:23 pm ESTSandra McGunigle - smcgunigle@manetchc.org added by Stefanie Curry - stefaniecurry@comcast.net as a CC'd Recipient Ip: 73.227.241.65
June 17, 2020 12:27 pm ESTSandra McGunigle - smcgunigle@manetchc.org added by Stefanie Curry - stefaniecurry@comcast.net as a CC'd Recipient Ip: 73.227.241.65
June 17, 2020 12:31 pm ESTSandra McGunigle - smcgunigle@manetchc.org added by Stefanie Curry - stefaniecurry@comcast.net as a CC'd Recipient Ip: 73.227.241.65
June 17, 2020 1:43 pm ESTSandra McGunigle - smcgunigle@manetchc.org added by Stefanie Curry - stefaniecurry@comcast.net as a CC'd Recipient Ip: 73.227.241.65
June 17, 2020 1:52 pm ESTSandra McGunigle - smcgunigle@manetchc.org added by Stefanie Curry - stefaniecurry@comcast.net as a CC'd Recipient Ip: 73.227.241.65
June 17, 2020 1:54 pm ESTSandra McGunigle - smcgunigle@manetchc.org added by Stefanie Curry - stefaniecurry@comcast.net as a CC'd Recipient Ip: 73.227.241.65
June 17, 2020 2:40 pm ESTSandra McGunigle - smcgunigle@manetchc.org added by Stefanie Curry - stefaniecurry@comcast.net as a CC'd Recipient Ip: 73.227.241.65