Express Care Of Tampa Bay, INC
    6496 US 41 N. Apollo Beach. Fl. 33572  Tel: 813-641-0068                                                                          107 Robertson St. Brandon. Fl. 33511 Tel: 813-651-4100
REGISTRATION FORM
Is this your legal name?
If not, what is your legal name?
(Former Name)
Birth Date
Age
Sex
[] Yes 
[] N0
 
Street Address
City
State
ZIP Code
Social Security#_______________
Home Phone No.
 
P.O. Box
City
State
ZIP Code
Occupation
Employer
Employer Phone No.
 
Chose Clinic Because/Referred to Clinic by (Please check one box)
  [] Dr.
[] Insurance Plan
[] Hospital
[]  Family
[]  Friend
[]  Close to Home/Work
[]  Yellow Pages
[]  Other
Other Family Members Seen Here
Reason For Today’s Visit::
INSURANCE INFORMATION
(PLEASE GIVE YOUR INSURANCE CARD TO THE RECEPTIONIST)
Person Responsible for Bill
Birth Date
Address (if different)
Home Phone No.
 
 
Is this person a patient here?
[] Yes
 [] No
Occupation
Employer
Employer Address
Employer Phone No.
 
 
Is this patient covered by insurance?
[] Yes
[] No
Please indicate primary insurance
[] Medicare
[]  Medicaid
  [] United
[] Tn-care  
[]BS/BC
 [] Humana
 [] Aetna
[]  Cigna
Other
Subscriber’s Name
Subscriber’s Social Security #
Birth Date
-
Group #
Policy #
 
                                                                                                                                                                                         Co-Payment amount $_____________
Patient’s Relationship to Subscriber
[]  Self
[]  Spouse
[] Child
[] Other
Name of Secondary Insurance (if applicable)
Subscriber’s Name
Group #
Policy #
Patient’s Relationship to Subscriber
[]  Self
[] Spouse
[] Child
[]  Other
IN CASE OF EMERGENCY
Name of Local Friend or Relative (not living at same address)
Relationship to Patient
Work Phone No
 
Home Phone No.
 
 
  
Consent For treatment: The undersigned authorizes the provider Express care to furnish medical treatment to include any necessary procedures. The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Express Care Clinic or insurance company to release any information required to process my claims. Refill policy: Patients must be seen for refill medication after 5 (five) days.
Medicare Patients: I have been given ABF notice, please initial ________ I am aware of HIPPA Policy initial. (____________). I am aware of Insurance coverage ( initial.___________)

x_________________________________________    _______________                      ________________
 PATIENT/GUARDIAN SIGNATURE                                                 Witness
DATE