Patient Registration Form

Patient Confidential Registration Form

Use this form to enroll with Dr. Tanenbaum or to update your registration information.
Please fill out all required* fields so we may properly identify you. Use the "Format" button below to review and print the completed form.

Patient Contact Information:

First Name*	Middle	Last Name*

Street Address:*
Street Address 2:
City:* State:* Zip:*
Home Phone xxx xxx-xxxx :* Soc. Sec. Nr. xxx-yy-zzzz :*
Date of Birth mm/dd/yyyy :* Gender:*

In case of Emergency , Contact:

Contact Name:

Relationship to Patient:

Contact Phone: Home: Work:

Responsible Party Information:

*Is the patient the responsible party?: yes or no?** (If yes, skip to Insurance below)
First Name	Middle	Last name

Street Address:
Street Address 2:
City: State: Zip:
Home Phone (xxx) xxx-xxxx : Sex: Male Female
Date of Birth mm/dd/yyyy : Soc. Sec. Nr. xxx-yy-zzzz :
Relationship to Patient:

Primary Insurance Information:

Insurance Company:

Employer:

Name of Insured:

Subscriber or ID Number:

Additional Insurance Information:

Insurance Company 2:

Employer 2:

Name of Insured 2:

Subscriber or ID Number 2:

Medicare#:
Medicaid#:

Is this a Workman's Comp or Auto Accident Claim?: Yes No (If yes, complete the following):

Claims Agent:

Claim #:

Terms and Conditions:

I understand that my account must be paid in full within 30 days unless other satisfactory financial arrangements are made with the doctor's office. All new patient visits are on a cash basis unless information is provided and approved.

In the event that I fail to pay this account as agreed above, I will pay all reasonable costs of collection of any debt incurred hereunder as a result of my default. If such action occurs, I understand that I will be unable to to continue care with the doctor or his ancillary staff.

I agree to allow the doctor's office to file complaints with the Colorado Insurance Commissioners Office should any insurance problems so warrant such contact.

I agree that I am solely responsible for the security, content, dissemination by any means and any other use of the information created by using this electronic form. Further, I hold Dr. Tanenbaum harmless for any or all consequences resulting from the dissemination of this information by means not under his care and control.

I have read this form and fully understand the conditions listed above and I certify that the information provided is accurate and correct. Accepted by entering full name below. *

Signature of Patient/Legal Guardian/Responsible Party

Check Results and Print:

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