Registration Form



"My primary concern as a physician is to always do what is in the best interests of my patients"
— Dr. Roger S. Madris
         
Name
Policy Holder's Date of Birth
Sex
Marital Status
Single
Married
Widowed
Separated
Divorced
Address (number, street, city, state and zip)
Home Phone
Cell Phone
Email
Occupation
Employer Name
Employer Phone
Address (number, street, city, state and zip)
How did you hear about our Practice/referred by?
 
 
Emergency Contact

Name

Address (number, street, city, state and zip)
Home Phone
Cell Phone
Relationship

 
Primary Insurance Information

Plan Name
ID Number
Address (number, street, city, state and zip)
Group Number
Policy Holder
Effective Date
Policy Holder's Date of Birth 
Sex

 
Secondary Insurance Information


Plan Name

 
 
 

ID Number

Address (number, street, city, state and zip)
Group Number
Policy Holder
Effective Date
Policy Holder's Date of Birth
Sex

 
Person responsible for bill (if different from patient)


Guarantor Name

Relationship to patient
Self Spouse Parent
Date of birth
Address (number, street, city, state and zip)
Phone
Employer Name
Employer Phone
Employer Address (number, street, city, state and zip)

I authorize the release of any medical information necessary to process this claim. I permit a copy of this authorization to be used in place of the original.

Date
Electronic Signature

I hereby authorize Dr. Madris to apply for benefits on my behalf for covered services rendered by him, or by his order.
I request that payment from my insurance company be made directly to Dr. Madris (or the party who accepts assignment).

I certify that the information I have reported with regard to my insurance coverage is correct.
 
I permit a copy of this authorization to be used in place of the original. This authorization may be revoked by either me or my insurance company at any time in writing.

Date
Electronic Signature



10 Rye Ridge Plaza Suite 105    |    Rye Brook, NY 10573   |   Phone: 914-253-6504 | Fax: 914-253-6507
 

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