Primary Care Associates of LVPG - lvhn 2025

1. Click ‘Get Form’ to open the Primary Care Associates of LVPG registration form in the editor.
2. Begin by entering today’s date at the top of the form. This helps keep your records organized.
3. Fill in the patient information section, including last name, first name, middle name, marital status, address, and social security number. Ensure accuracy for seamless processing.
4. Provide contact details such as home phone number, cell phone number, and spouse’s name with their phone number if applicable.
5. Complete the occupation and employer fields along with their respective phone numbers. This information is crucial for insurance purposes.
6. In the insurance information section, indicate who is responsible for the bill and provide their birth date and address if different from the patient’s.
7. Enter primary insurance details including subscriber's name, social security number, birth date, group number, policy number, and co-payment amount.
8. If applicable, fill out secondary insurance information similarly to ensure comprehensive coverage.
9. In case of emergency section, list a friend or relative's name not living at the same address along with their relationship to the patient and contact numbers.
10. Finally, review all entered information for accuracy before signing at the bottom of the form to authorize payment and release of information.

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