NORTHEAST MISS看SSIPPI HEALTH CARE, lNC. PATIENT RたGISTRAT10N FORM Patient しast Name Address (Street, Citv, State, Zip, County〉 First Name CHART # MI Areyou ofしatino/Hispanic Descent? ( )YES ( 〉 NO Date of B而h Sociai Security # Home Phone Provider of Choice? Preferred Language ( ) ENGLISH ( ) SP Special Communication Needs? Ema= Ce= Phone MARITAしSTATUS: □ Singie □ Married ロWidowe ETHNIC晴Y:(CheckailthatappIy) 口Asian 口NativeAmeric 口Black/AfricanAmerican 口AmericanI □OtherPacificIslander 口Morethano lNCASEOFEMERGENCY,WHOSHOUしDBENOTiFiED? NAME NAME REしA丁IONSHIP RELATIONSHIP pHONE# PHONE# AUTHORIZATION FOR HEA町H CARE l. 1 give permission to the Medica- Denta- Providers at NEMH responsible as the P「ovider advises as necessary in the case of 2. 1 hereby authorize NEMHC′血・ tO furnish such professiona冊or records compi-ed by NEMHC′ lnc.′ inc-uding professiona- serv liab冊y that may arise from the release ofthe information requ 3. I/we agree to ACCEPT COMPLETE RESPONSIBILITY for a-1 ch same at the time services are rendered or no -ater than 90 days payment (non-COVered Medicare′ Medicaid′ Private insurance cha costs of co=ection, including reasonable attomey fees. 4. 1 agree that I have read and understand the above consent an SIGNATURE OF PATiENT/RESPONS 1
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NORTHEAST MISS看SSIPPI HEALTH CARE, lNC. CHART · records compi-ed by NEMHC′ lnc.′ inc-uding professiona- services′ and hereby release NEMHC′ lnc. from aIi liab冊y that
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NORTHEAST MISS看SSIPPI HEALTH CARE, lNC.
PATIENT RたGISTRAT10N FORM
Patient
しast Name
Address (Street, Citv, State, Zip, County〉
First Name
CHART #
MI
Areyou ofしatino/Hispanic Descent? ( )YES ( 〉 NO
Date of B而h
Sociai Security #
Home Phone
Provider of Choice?
Preferred Language ( ) ENGLISH ( ) SPANISH
Special Communication Needs?
Ema=
Ce= Phone
MARITAしSTATUS: □ Singie □ Married ロWidowed 口Divorced