Patient Information

Patient Registrant Information
First name: Last name: MI:
Home phone: - - Work phone: - -
Address: City:
State: Zip:
Date of birth: / / Age:
Gender: Social Security Number:
Driver's License Number: Reason for visit:
Emergency contact: Relationship:
Phone: - - Referred by:
Primary physician: Are you employed?
Are you a student? Marital status:
Is the patient: a minor child* an adult dependent*
*If you checked either, please see receptionist for additional information.
Primary Insurance Information
Please present your card at each visit. Deductible amount: Co-pay amount: PCP:
Insurance company name: Claims address:
State: Zip:
Phone: - - Contact person:
Group number: Policy number:
Primary insured: Insured's date of birth: / /
Insured's Social Security Number: Relationship to patient:
Employer:    
Secondary Insurance Information
Please present your card at each visit. Deductible amount: Co-pay amount: PCP:
Insurance company name: Claims address:
State: Zip:
Phone: - - Contact person:
Group number: Policy number:
Primary insured: Insured's date of birth: / /
Insured's Social Security Number: Relationship to patient:
Employer:    
Accident Information
Is this illness/injury the result of an accident? Where did it occur?
Date of accident: / / Have you reported the illness/injury to your employer?
Patient's initials:    
Assignment of Benefits/Release of Information/Notice of Privacy Practices/Appointment of Authorized Representative
Please read and initial each paragraph.
Texas Health Physicians Group, a Texas Health Resources (THR) entity, and associated physicians are committed
to securing the privacy of your health information. We are supplying you with a copy of our Notice of Privacy Practices. You
are not required to read this notice. By initialing, you are acknowledging receipt of this notice.
I request that payment of authorized Medicare and other insurance benefits be made on my behalf to Texas Health
Physicians Group for any services furnished to me by any healthcare providers associated with that group. I authorize any
holder of medical information about me to release to the Health Care Financing Administration and its agents or insurance
company for any information needed to determine these benefits or the benefits payable for related services.
I appoint Texas Health Physicians Group to act as my authorized representative in requesting an appeal from my
insurance plan regarding its denial of services or denial of payment.
Unless I request to the contrary, in writing, I will receive appointment reminders on my home telephone answering
system and/or appointment reminder cards sent by mail, whichever is the policy of this practice.
Patient Financial Responsibility Statement
In order to maintain our fees at the lowest possible level, it is important that we have a good understanding with our patients
regarding financial responsibility. We hope that this summary will be helpful toward that end. We encourage you to discuss
it with us and to ask questions.

We understand that your health coverage is provided through
  • If you have out-of-network benefits, we will happily file claims on your behalf.
  • You must pay any co-payment and applicable deductible amounts at the time of service unless other arrangements have been made with our office.
  • The remainder of your bill will be sent to your health plan for direct payment to our office.
  • If your insurance carrier has not paid our claim within 45 days, we will expect payment from you.
  • If, by mistake, your health plan remits payment to you, please send it to us along with all paperwork sent to you at the time.
  • You will remain responsible for amounts and any services that are not covered by your insurance plan.
  • Your health plan may refuse payment of a claim for some of the following reasons:
    1. This is a pre-existing illness that is not covered by your plan
    2. You have not met your full calendar year deductible
    3. The type of medical service required is not covered by your plan
    4. The health plan was not in effect at the time of service
    5. You have other insurance which must be filed first

Please understand that financial responsibility for medical services rests between you and your health plan. While we are pleased to be of service by filing your medical insurance for you, we are not responsible for any limitations in coverage that may be included in your plan. If your health plan denies this claim for any of these or other reasons, our office cannot be responsible for this bill. It is your responsibility as the patient to pay the denied amounts in full.

Our primary mission is to provide you with quality, cost effective, medical care. Together we are trying to adapt to the changing
way that health care is financed and delivered. Again, we value you as a patent and our first priority is to provide you with
the best possible care. With this housekeeping chore complete, we are pleased to serve you.

Sincerely,
Texas Health Physicians Group