Centura Health

 
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Centura Health

Patient Pre-Registration Form

Please complete the patient Pre-registration form. After you submit this form you may choose to move on to step 2 and complete the Patient Health History form online.

* Indicates required information
First Name * 
Middle Initial * 
Last Name * 
I prefer to be called: * 
Date of Birth *  (mm/dd/yyyy)
Street Address 1 * 
Street Address 2 
City * 
County * 
State * 
Zip * 
Main Phone Number * 
Cell Phone 
Work Phone 
Email Address 
Social Security Number 
Marital Status 
Race 

If Other, please specify:

Religion 
Primary Care Doctor/Practice 
Primary Care Phone Number 
Employer * 
Occupation * 
Insurance Information 
Insurance Company  * 
Member ID# * 
Insurance Company Address * 
Effective Date of Policy * 
Copay Amount * 
Group Number * 
Policy Holder Name * 
Policy Holder SSN * 
Policy Holder Date of Birth *  (mm/dd/yyyy)
Relationship to Patient * 



If Other, please specify:

Policy Holder Sex * 

Employer Name & Occupation * 
Secondary Insurance Information 
Insurance Company 
Member ID# 
Claims Address 
Policy Effective Date 
Group# 
Policy Holder Name 
Policy Holder SSN# 
Policy Holder Date of Birth  (mm/dd/yyyy)
Relationship to Patient * 



If Other, please specify:

Policy Holder Sex * 

Policy Holder Employer Name/Occupation 
Guarantor Information (Person responsible to pay bill) 
Guarantor Name (First & Last) * 
Guarantor Date of Birth  *  (mm/dd/yyyy)
Guarantor SSN# * 
Relationship to Patient * 



If Other, please specify:

Guarantor Employer Name/Occupation * 
Emergency Contact (Spouse or Next of Kin) 
Emergency Contact Name * 
Relationship to Patient * 


If Other, please specify:

Main Phone * 
Work Phone 
Are there any learning barriers or communication needs we need to be aware of? If yes, please explain. 
Do you have a preferred learning method? * 

Please type your full name in the box as an electronic signature and agreement to the statement below.  * 
Authentication * 

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Deductibles, co-payments and payments for non-covered services are required at the time of service. Our office will only file a claim with an insurance company with whom we have a contract. I understand that accounts more than 90 days past due may be turned over to collections and any legal fees or costs will be my responsibility. I authorize my insurance benefits to be paid directly to the treating physician, realizing I am responsible to pay non-covered and unaurthorized services, and I hereby authorize the release of pertinent medical information of insurance carrier.

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