PATIENT PRE-REGISTRATION FORM
Please fill out this form as completely as possible. This completed form will save valuable time for both you and the office upon your arrival.
* Required Fields
Areas in yellow are for OFFICE USE ONLY.
ID:
Company:
PCC:
Scheck & Siress office where you will be seen:
*
Bannockburn
Hickory Hills
Lincoln Park
Naperville
Oakbrook
Oak Park
Rush (RUMC)
Schaumburg
Schererville, IN
UIC
What is the reason for your visit?
*
Orthotic
Prosthetic
Foot Orthotic
Other
Other Reason:
Is your visit related to an injury that occurred at work?
*
Yes
No
Marital Status:
*
Single
Married
Divorced
Widowed
Spouse Name:
First:
Last:
Name of Patient:
*
Last
Prescribing Doctor:
Address:
*
Phone:
123-456-7890
City
*
/ State
*
/ Zip:
*
Primary Care Doctor:
Phone:
*
123-456-7890
Phone:
123-456-7890
Date of Birth:
*
(mm/dd/yyyy)
Diagnosis:
Sex:
*
M
F
Employment Status:
Full Time
Part Time
Disabled
Retired
Student
Unemployed
SS#
123-45-6789
Patient's Employer:
Cell Phone:
123-456-7890
Address:
1
E-Mail Address:
City:
St:
Zip:
Phone:
123-456-7890
1
Email address is for a patient newsletter and will not be used for any third party or spam. We will never share, sell, or rent individual personal information with anyone without your advance permission or unless ordered by a court of law. Information submitted to us is only available to employees managing this information for purposes of contacting you or sending you emails based on your request for information and to contracted service providers for purposes of providing services relating to our communications with you.
Emergency Contact:
Emergency Contact Phone:
123-456-7890
Do you have insurance?
*
Yes
No
How many insurance policies do you have?
*
1
2
3
PRIMARY INSURANCE INFORMATION
Insurance Holder's Relationship to Patient:
Self
Spouse
Mother
Father
Other:
Insurance Carrier:
Blue Cross/Blue Shield
Medicaid
Medicare
Medicare HMO
Other
Unicare
Workers Comp
ID#
*
Name of Card Holder:
Group#
*
SS# of Card Holder:
123-45-6789
Insurance Address:
D.O.B of Card Holder:
(mm/dd/yyyy)
Insurance City, St & Zip
Cardholder's Employer:
Phone:
123-456-7890
Phone:
123-456-7890
SECONDARY INSURANCE INFORMATION:
Insurance Holder's Relationship to Patient:
Self
Spouse
Mother
Father
Other:
Insurance Carrier:
None
Blue Cross/Blue Shield
Medicaid
Medicare
Medicare HMO
Other
Unicare
Workers Comp
ID#
*
Name of Card Holder:
Group#
*
SS# of Card Holder:
123-45-6789
Insurance Address:
D.O.B of Card Holder:
(mm/dd/yyyy)
Insurance City, St & Zip
Cardholder's Employer:
Phone:
123-456-7890
Phone:
123-456-7890
How did you hear about Scheck & Siress?
Doctor
PT/OT
Insurance
Website
Friend
Other
TERTIARY INSURANCE INFORMATION
Insurance Holder's Relationship to Patient:
Self
Spouse
Mother
Father
Other:
Insurance Carrier:
None
Blue Cross/Blue Shield
Medicaid
Medicare
Medicare HMO
Other
Unicare
Workers Comp
ID#
*
Name of Card Holder:
Group#
*
SS# of Card Holder:
123-45-6789
Insurance Address:
D.O.B of Card Holder:
(mm/dd/yyyy)
Insurance City, St & Zip
Cardholder's Employer:
Phone:
123-456-7890
Phone:
123-456-7890
EARLY INTERVENTION/ DSCC / MEDICAID
Please select your insurance carrier:
Please choose one..
Early Intervention
DSCC
Medicaid
Case Worker's Name:
Phone:
Fax:
123-456-7890
If you have insurance through another source and the insured is still working, we need to know how many people are
employed in that company:
0-24
25-99
100+
I AUTHORIZE THE RELEASE OF ANY INFORMATION ABOVE NECESSARY TO PROCESS MY INSURANCE AND AUTHORIZE PAYMENT TO BE MADE DIRECTLY TO SCHECK & SIRESS PROSTHETICS, INC. PAYMENT IN FULL IS REQUIRED AT THE TIME SERVICES ARE RENDERED. IF PRIMARY INSURANCE IS ACCEPTED, ALL OPEN DEDUCTIBLES AND CO-INSURANCE FEES WILL BE COLLECTED FROM THE PATIENT AT THE TIME OF THE VISIT. ALL FEES NOT COVERED BY OR COLLECTED FROM INSURANCE CARRIER WILL BE THE PATIENT'S RESPONSIBILITY.
Signature:
_________________________________________________
Date:
_______________________