Get Patient Registration - Plastic Surgery Pittsburgh

Completing the PATIENT REGISTRATION form for Plastic Surgery Pittsburgh online is a straightforward process. This guide will help you understand each section of the form, ensuring that you provide all necessary information accurately.

Follow the steps to successfully complete your registration form.

1. Click ‘Get Form’ button to access the registration form and open it in your browser.
2. Begin by entering today’s date at the top of the form. This ensures that your registration is current.
3. Provide your personal information in the PATIENT INFORMATION section. Fill in your full name, birth date, social security number, age, sex, and marital status.
4. Next, include your address, city, state, and zip code. Ensure your contact information is accurate by entering your home and work phone numbers.
5. Identify your employer, occupation, and employment status, selecting from full-time, part-time, or not employed as applicable.
6. Complete the EMERGENCY CONTACT sections by adding information for two emergency contacts, including their relationship to you and their contact numbers.
7. Enter the name and phone number of your primary care physician in the relevant section.
8. Indicate how you heard about Plastic Surgery Pittsburgh, providing any relevant details.
9. If you are not the patient but are responsible for the bill, fill out the PERSONAL RESPONSIBLE FOR BILL section with the requested information.
10. Complete the PRIMARY INSURANCE section, entering the insurance provider's name, copay amount, subscriber information, and policy details.
11. If applicable, repeat the same process for the SECONDARY INSURANCE section.
12. If your claim involves worker’s compensation or an auto accident, provide detailed information in the WORKER’S COMPENSATION/AUTO sections.
13. Review all entered information for accuracy and completeness to ensure there are no errors.
14. Once finished, you can save changes directly, download a copy for your records, print the form, or share it as needed.

Begin your registration process online today by following the steps outlined above.