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Patient Registration Form-Mass Vaccination

  1. Hoke County Health Department

    Patient Registration Form-Mass Vaccination

  2. Sex:

  3. Person Responsible for bill (ONLY IF DIFFERENT THAN THE PATIENT)

  4. Additional Information (PLEASE FILL OUT ALL FIELDS BELOW)

  5. Can we leave a message regarding your medical care & test results?*

  6. Race:*

  7. Ethnicity:*

  8. Preferred Language:*

  9. Insurance Information

    Primary Policy Holder Information (ONLY IF DIFFERENT THAN THE PATIENT OR RESPONSIBLE PARTY)

  10. PRIMARY MEDICAL INSURANCE

  11. SECONDARY MEDICAL INSURANCE

  12. I have read and agree to the Hoke County Health Department’s (HCHD) payment policy. I understand that payment is my responsibility regardless of insurance coverage. I hereby assign to HCHD all money to which I am entitled for medical expenses related to the services performed from time to time by HCHD, but not to exceed an indebtedness to HCHD. I understand that failure to pay outstanding balances within 90 days of notification of the amount due will result in submission to an outside collection agency.

  13. MEDICARE BENEFICIARIES: I request that payment of authorized Medicare benefits be made to HCHD. I authorize any holder of medical information about me to release to CMS and its agents any information needed to determine these benefits or the benefits payable for related services.

  14. DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

  15. Leave This Blank:

  16. This field is not part of the form submission.