New Patient Account Information

Please print and fill out this form to register as an Austin Regional Clinic patient. All fields with an asterisk (*) are required fields. We cannot register you as an ARC patient without that information.Please fax the completed form to our Central Registration Department at (512) 406-6228.

Call our Central Reigstration line at 407-6446 for any questions.

 

Appointment Location ___________________ Appointment Date ___________________

Patient Information Patient ID#: _____________________
*First/Last Name:___________________________________ *Soc. Sec #:_____________________
*Address:__________________________________________ *DOB:_________________________
*City, State, Zip:____________________________________ Sex: M or F
*Home Phone:______________Alt Phone:_______________ *M.S.: Single or Married
*Employer/School:__________________________________ *Emp Status: FT PT UN Ret
FT / PT Student
Address:_________________________________________ Wk Phone: _____________________
City, State, Zip:____________________________________   Ext: ____________________
Occupation:__________________________________________________________________________

Guarantor Information (person responsible for the bill)

  
*First/Last Name:___________________________________ *Soc. Sec #:_____________________
*Address:__________________________________________ *DOB:__________________________
*City, State, Zip:____________________________________ Sex: M or F
*Home Phone:______________Alt Phone:_______________ M.S.: Single or Married
Employer/School:__________________________________ Emp Status: FT PT UN Ret
FT / PT Student
Address:_________________________________________ Wk Phone: _____________________
City, State, Zip:___________________________________   Ext: ____________________
Occupation:_______________________________________   *Rel to Patient: __________________

Subscriber Information (person that has the policy)

  
*First/Last Name:___________________________________ *Soc. Sec #:_____________________
*Address:__________________________________________ *DOB:_________________________
*City, State, Zip:____________________________________ Sex: M or F
Home Phone:______________Alt Phone:_______________ M.S.: Single or Married
*Employer/School:__________________________________ Emp Status: FT PT UN Ret
FT / PT Student
Address:_________________________________________ Wk Phone: _____________________
City, State, Zip:___________________________________   Ext: ____________________
Occupation:__________________________________________________________________________

Primary Coverage

  
*Subscriber:___________________________________  
*Insurance Comp: ______________________________ Plan Type:_________________________
*Claims Address: ______________________________ Policy ID:_________________________
*City/State/Zip: ________________________________ *Patient ID: ________________________
*Phone: ______________________________________ *Group #: __________________________
*Patient's PCP:________________________________ O/V Co-Pay: ______________________
Effective Dates: _______________________________   Verified by: ________________________

Secondary Coverage

  
Subscriber:___________________________________  
Insurance Comp: ______________________________  
Claims Address: ______________________________ Policy ID:_________________________
City/State/Zip: ________________________________ Patient ID: ________________________
Phone: ______________________________________ Group #: __________________________
Patient's PCP:________________________________ O/V Co-Pay: ______________________
Effective Dates: _______________________________   Verified by: ________________________

Emergency Contact
*First/Last Name:___________________________________
Address:__________________________________________
City, State, Zip:____________________________________
*Home Phone:______________Alt Phone:_______________
*Relation to Patient: _________________________________

For Internal Use Only

Information Obtained by:________________________________ Date: ______________________________

Account Created by: ___________________________________ Date: ______________________________