Creating Patient Registration Forms

Create a Patient Registration Form to Capture and Update Insurance Information

Getting patient registration information is the first step in getting your medical claims paid. Failure to capture accurate patient identification, demographics or insurance information can lead to claim denial. The number one reason why most medical billing claims are denied is a result of not verifying insurance coverage. Because insurance information can change at any time, even for regular patients, it is important that the provider verifies the member's eligibility each and every time services are provided.

Create a Registration Form Template

Woman sitting in waiting room filling out forms
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This registration form template lists the information that the medical office needs to include when creating a registration form. As you prepare your registration form template, use the following information to include or give you ideas about what should be included on your customized registration form.

Identify Your Practice at the Top of the Registration Form

Include at the top of the patient registration form information about your facility and the provider, as well as the date:

  • Your practice name
  • Today's date
  • The PCP's name

Patient Information Section of the Registration Form

The first section should include the patient's personal information.

  • Last name, first name and middle initial
  • Marital status
  • Social security number
  • Birth date
  • Sex
  • Physical address, mailing address, city, state, and zip code
  • Home phone number and cell phone number
  • Employer, occupation, and employer phone number

Optional information for the patient information section

  • Email address
  • Referral physician's name, office name or hospital
  • Other family members seen by the practice
  • Nickname or former name

Insurance Information Section of the Registration Form

This section should include the insurance information in order to accurately file the medical claim to the insurance carrier and the patient. Remember that this section must be reviewed and updated at each visit or time a service is provided.

  • Responsible party name
  • Responsible party birth date
  • Responsible party address
  • Responsible party phone number
  • Responsible party employer, occupation and employer phone number
  • Primary insurance name
  • Subscriber's name
  • Subscriber's social security number
  • Subscriber's birth date
  • Subscriber's policy number
  • Subscriber's group number
  • Patient's relationship to the subscriber
  • Secondary insurance name
  • Subscriber's name
  • Subscriber's social security number
  • Subscriber's birth date
  • Subscriber's policy number
  • Subscriber's group number
  • Patient's relationship to the subscriber

More

In Case of Emergency Section of the Registration Form

This section should include a friend or family member not living in the patient's home to be able to contact in the event the patient can not be contacted.

  • Friend or family member's name
  • Relationship to the patient
  • Home phone number
  • Mobile or work phone number

Consent for Treatment Section of the Registration Form

The last section is to obtain patient signatures to authorize or consent treatment, assignment of benefits, and release of information authorization.

Include a signature line with the date and the following statements:

The above information is true to the best of my knowledge.

  • I authorize the physicians of (your practice name) to provide myself (or dependent) with reasonable and proper medical care.
  • I authorize my health insurance company or third party payer to pay my insurance benefits directly to (your practice name).
  • I authorize (your practice name) to release any information required to process my insurance claim.
  • I understand that I am ultimately financially responsible for any balance remaining on the account after insurance has paid or total charges even if the insurance is pending or has denied.

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Formatting Your Registration Form

Be sure to print the form with a font size large enough for reading by people who have aging eyes. Allow enough space between lines so your clients can write the answers clearly without having to use cramped handwriting. While this may result in a form that is two or more pages, it will help ensure both the questions and answers are readable.

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