Patient Registration  Form Template

This Patient Registration  Form Template was created using Captisa Form Builder framework.

 

A streamlined pre-registration process saves time and reduces paperwork for both the patient and the team.

Helping your patients with registration saves them time trying to understand and accurately answer registration questions presented to them in paper form. Physicians and other care team members can also spend more time on the visit and less time on paperwork while being confident they have a complete medical history.

 

A new patient coordinator (NPC) conducts new patient pre-registration over the phone or in person prior to the initial visit. This conversation enables the new patient coordinator to capture all of the required demographic and payment information in the registration record and enter medical information, including medication list, allergies, and medical history, directly into the electronic health record (EHR) to reduce the data entry work required of clinicians at the patient's initial visit. Eliminating paper and entering information directly into your practice's registration software and EHR prevents mistakes. Emerging technologies may further streamline patient registration, including patient portals or kiosks that allow patients to enter a great deal of registration information themselves.

I, {{data.fn_ngjsz1scb7.c || 'No Name'}}, certify that I have read and agree to Captisa Medical Group (CMG) payment policy. I am eligible for the insurance indicated on this form and I understand that payment is my responsibility regardless of insurance coverage. I hereby assign to CMG all money to which I am entitled for medical expenses related to the services performed from time to time by CMG, but not to exceed my indebtedness to CMG. I authorize CMG to release any medical information to my insurance carrier or third party payer to facilitate processing my insurance claims. I understand that failure to pay outstanding balances within 90 days of notification of the amount due will result in submission to an outside collection agency. A $10.00 returned check fee will be charged for checks returned due to insufficient funds. I choose to receive  communications from CMG by text or e-mail at the number or address stated above, including but not limited to communications about appointments, feedback, treatment, and payment. I understand that such e-mails and texts may not be secure and there is a risk that they may be read by a third party.