Embedded Files
Registration Check List
<make sure you select ALL and confirm we don’t already have a chart>
<make sure you select ALL and confirm we don’t already have a chart>
When scheduling a FU, EST NI or NEW2DOC please confirm we have all this info
When scheduling a FU, EST NI or NEW2DOC please confirm we have all this info
Last name
Last name
We must obtain Middle Initial for Medicare Patients
We must obtain Middle Initial for Medicare Patients
First name (add preferred name in appropriate spot if they have one*)
First name (add preferred name in appropriate spot if they have one*)
If patient is a minor, it is required to obtain parent/guardian's information. Place information in the Patient Responsible Required field
If patient is a minor, it is required to obtain parent/guardian's information. Place information in the Patient Responsible Required field
(See below for example)
(See below for example)
Mailing address (hit the validate button) If International, per billing, no longer put in the country under state/province. That field is to be left blank.
Mailing address (hit the validate button) If International, per billing, no longer put in the country under state/province. That field is to be left blank.
Phone number (add it in both home and cell, Reminder when child becomes of age please change phone to reflect patient's phone) **
Phone number (add it in both home and cell, Reminder when child becomes of age please change phone to reflect patient's phone) **
Email address (If someone wants to change their email always disable first and then change the email, Reminder when child becomes of age disable parent's email and put in patient's new email)
Email address (If someone wants to change their email always disable first and then change the email, Reminder when child becomes of age disable parent's email and put in patient's new email)
Date of Birth
Date of Birth
Social Security Number (let them know it’s needed for insurance verification/for Self Pay patients this is a requirement to have if they are US citizen. Please put in all 1's when the pt does not know the number or do not want to give it over the phone. They can punch it in when they come in for their appt. Use all 0's when the patient is NOT a US citizen and would not have a SS#)
Social Security Number (let them know it’s needed for insurance verification/for Self Pay patients this is a requirement to have if they are US citizen. Please put in all 1's when the pt does not know the number or do not want to give it over the phone. They can punch it in when they come in for their appt. Use all 0's when the patient is NOT a US citizen and would not have a SS#)
PCP (if they are not in the system, give Manager the info needed)
PCP (if they are not in the system, give Manager the info needed)
Referring Provider (if they are not in the system, give Manager the info needed)
Referring Provider (if they are not in the system, give Manager the info needed)
Rendering Provider (who are they going to see)
Rendering Provider (who are they going to see)
Language
Language
Race
Race
Ethnicity
Ethnicity
Insurance Information (add primary card holder info if it’s not the Pt.)
Insurance Information (add primary card holder info if it’s not the Pt.)
· Last, First, M.I. if it’s on the card and DOB
· Last, First, M.I. if it’s on the card and DOB
Responsible Party (self if over 18, parent/ guardian for under 18, Reminder when child becomes of age please change to self)
Responsible Party (self if over 18, parent/ guardian for under 18, Reminder when child becomes of age please change to self)
*After appt. has been made
*After appt. has been made
-please verify insurance
-please verify insurance
- Send insurance text message
- Send insurance text message
- add to NP tracking sheet
- add to NP tracking sheet
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