Channel Islands Family Practice and Urgent Care

2103 Pickwick Dr.

Camarillo, CA 93010

Patient Registration Information

Name ________________________________________ Social Security _______________________

Date of Birth _______________ Age ______ Marital Status: Single____ Married____ Divorced____

Address __________________________apt______ City ________________ State ____ Zip _______

Home Phone # ___________________________Cell Phone #________________________________

Employed by _______________________________ Phone # ________________________________

Address ___________________________________________________________________________

Who to Notify in Case of Emergency _________________________ Phone _____________________

Email Address:_____________________________(for important medical information)

Reason for Visit: Illness__ Injury__ Job Related Injury__ Auto Accident

How did you hear about our clinic? Yellow Pages__ Newspaper__ Other________________________________

Responsible Party for Payment

Name _________________________________ Social Security # _____________________________

Address___________________________ City_____________________ State_____ Zip __________

Relationship to Patient ____________________________ Phone # ____________________________

Employed by ___________________________________ Phone # ____________________________

Medical Insurance Information (primary card holder information)

Insured Name __________________________________ Date of Birth _________________________

Insured Social Security # ________________________ Relationship to Patient __________________

Insurance Company ______________________________ Phone # ____________________________

Address _____________________________ City ___________________ State_____ Zip __________

Policy/Subscriber # ______________________________ Group # _____________________________

Please Sign and Return to Receptionist

I, the undersigned, have insurance coverage with, ____________________ and assign directly to Channel Islands Urgent Care all surgical and medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I also agree that I will be charged a $15.00 late fee every 30 days that my balance goes unpaid. I hereby authorize the doctor to release all information necessary in accordance with the Hippa Privacy Act (a complete copy available for you to review), to secure the payment of benefits. The undersigned gives consent for treatment.

_______________ ________________________________________________________

Date Patient / Responsible Party