Bay Area Heart

Dr. Rakesh Shah ∙ Dr.

Jinesh Shah ∙ Dr. Francis Uricchio ∙ Dr. Andrew Badalamenti

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NEW PATIENT REGISTRATION

Address
Gender:
Marital Status:
Race:
Ethnicity:
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RESPONSIBLE PARTY (If different from patient)

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PRIMARY INSURANCE

SECONDARY INSURANCE

PLEASE SIGN THE FOLLOWING STATEMENTS:

I authorize payment of medical benefits to the named provider for professional services rendered. I authorize the release of any medical information necessary to process the claim. I understand that I am financially responsible for any balance. I have been given a copy of the patient’s rights and privacy act.

I hereby authorize my test results to be left on the answering machine at the following

I authorize my test results to be given to the following person: