Alexander Health Center

Patient Registration Form

Date:_______________

PERSONAL INFORMATION:

Patient’s Full Name:_______________________________________________________ Date of Birth:_____________ Age: _________

Campus Phone: _________________________________  Campus Address:_______________________________________________

Home Phone: ____________________________________  Emergency Contact & Phone:_____________________________________

Home Address: _______________________________________  City:________________________  State:_____  Zip:_____________

TU I.D. Number: _________________________________

INSURANCE SECTION:

Primary Insurance Company:_______________________________________________________

Policy/I.D. Number:______________________________________ Group Number:__________________________________________

Medical Claim Address:_________________________________________________________________________________________

Policy Holders Full Name: ______________________________________________________Policy Holders Date of Birth:___________

Employer’s Name: ____________________________________


AUTHORIZATION FOR TREATMENT: By virtue of my signature I authorize the University of Tulsa and any of its employees or other authorized personnel or agents to provide general healthcare service to me. PAYMENT AGREEMENT: I understand I am responsible for any portion of my bill not covered by my insurance company. Payments not timely made will be treated as a debt to the University of Tulsa and processed through the Business Office. I herby authorize applicable third-party payments directly to the Alexander Student Health Center.

RELEASE OF INFORMATION: I authorize the release of all or part of the patient’s medical record for this period of care to any person or corporation liable for any part of the physician charges. Oklahoma State Law (63 O.S. 1-503.3 and 1-502.3) requires that we advise, “The information authorized for release may include information which may be considered a communicable or venereal disease including but not limited to Hepatitis, Syphilis, Gonorrhea, Human Immunodeficiency Virus (HIV), and acquired Immune Deficiency Syndrome (AIDS).”
 

____________________________________________________________________                                                                ________________________________________________________________
Patient or Authorized Signature                                                                                                                                                                                         Relationship