Patient registration form - Family Medicine Centers of South Carolina 2025

1. Click ‘Get Form’ to open the patient registration form in the editor.
2. Begin by entering your personal information. Fill in your name, age, race, sex, and address. Ensure that all details are accurate for effective communication.
3. Provide your birth date, religion, marital status, and social security number. This information is crucial for identification and insurance purposes.
4. Next, indicate your employment details including employer name and address. If applicable, provide information about the responsible party if you are not the patient.
5. Fill out insurance details. Specify if you have Medicaid as a primary or secondary plan and provide information for both primary and secondary insurance providers.
6. Complete the pharmacy section by providing the names and addresses of your local and mail-order pharmacies.
7. Review the authorization sections carefully. Sign where indicated to authorize release of information and assignment of benefits.
8. Finally, ensure all contact preferences are filled out accurately so that Family Medicine Centers can reach you effectively.

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