Date of Birth:
Social Security #:
Please check if you are: Please check if you are:
Are you head of household?
Number of Dependents:
Do you have insurance?
Please select the patient's relationship to Insurance Card Holder:
Name of person who gets this insurance:
Subscriber's date of birth:
Subscriber's telephone #:
Name of Insurance Plan:
Doctor or Health Center Name listed on your card:
SECOND INSURANCE PLAN:
If patient is a child:
Billing Address (if different from above address):
PERSON YOU WANT CALLED IN AN EMERGENCY:
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.
Indicate relationship if 'other':
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Registration Form
Agree & Sign