Drug Treatment and Addiction Recovery: Center for Addiction Medicine

PATIENT REGISTRATION
Doctors are required by the new Federal HIPPA laws to adhere to the highest privacy standards possible in order to protect patient confidentiality. We have provided this secure, confidential environment for you to conveniently complete your Patient Registration with us before your appointment. Please fill out the following form which we will print, have you sign when you arrive at our office and keep on record in our confidential files.

YOU ARE NOW IN A SECURE WEBSITE ENVIRONMENT - read more
Use this convenient online form to submit your information before arriving to our office.

PATIENT REGISTRATION
Patient Name:	(Last, First, Middle)
Your Email Address:	If you do not have an email address, please put none@addictionhelp.com in this field.
Date of Birth:	mm/dd/yyyy
Age:
Gender:
Social Security Number:
HOW TO REACH YOU
Mailing Address:
City:
State:
Zip Code:
Home Phone:	area code + phone number
Cell Phone:	area code + phone number
Work Phone:	area code + phone number
Employer Name:
SIGNIFICANT OTHER INFORMATION
Marital Status:
Spouse Name:	(Last, First, Middle)
Spouse Date of Birth:	mm/dd/yyyy
Spouse Social Security Number:
PRIMARY INSURANCE INFO
Insurance Name:
I-Mailing Address:
I-City:
I-State:
I-Zip Code:
I-Phone:	area code + phone number
Insured/Subscriber Name:
Relationship:
Subscriber ID #:
Group #:
ADDITIONAL BILLING INFORMATION
Name of nearest relative not living with patient:	(Last, First, Middle)
R-Mailing Address:
R-City:
R-State:
R-Zip:
R-Phone:	area code + phone number
ADDITIONAL INFORMATION
For confidentiality purposes, we need you to indicate below what phone number we may contact you at:
Confidential Phone:
Do you give us permission to contact you at the confidential phone number indicated herein?
Your Signature
Selecting 'yes' in this online registration form is recognized as a legal endorsement. Actual signature will be obtained before or at your first office visit. Thank you for using this convenient, secure, online form:	yes no

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