Radiology Registration

Baylor Scott & White Medical Center Frisco
5601 Warren Parkway, Frisco, TX 75034

Radiology Registration Form

Completion of this form allows us to register you & file with your insurance.

NOTE: * Denotes Required Field.

Registration Type:*

Registration for Radiology

Patient Name:*

First NameLast Name

Date of Birth:*

MonthDayYear

Gender:*

MaleFemale

Address*

Street Address

Apt. # (if applicable)

CityState / Province

Postal / Zip CodeCountry

Patients Phone #*

Area CodePhone Number

E-mail*

Marital Status

MarriedSingleDivorced

Social Security #:*

Race:*

Religion:

Primary Care DR*

Employer Name:*

Employer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employer Phone #:

Area CodePhone Number

Occupation

Referring Physician's Name Name:

Date of Surgery:

MonthDayYear

Emergency Contact:

Emergency Contact Name:*

Address (if different then Patient):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Contact's Phone #:*

Area CodePhone Number

Relationship to Patient:*

Insurance Provider Information:

Insurance Provider:*

ID #:*

Group #:*

Policy Holder Name:*

First NameLast Name

Policy Holder Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Policy Holder DOB:*

MonthDayYear

Policy Holder Social Security #:

Policy Holder Relationship to Patient:*

Policy Holder Employer Name:

Policy Holder Employer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Secondary Insurance Provider Information (if applicable):

Insurance Provider:*

ID #:

Group #:

Policy Holder Name:

First NameLast Name

Policy Holder Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Policy Holder DOB:

MonthDayYear

Policy Holder Social Security #:

Policy Holder Relationship to Patient:

Policy Holder Employer:

Policy Holder Employer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

To expedite your check-in process, please have your Current Insurance Card and Picture ID available.

The document(s) accompanying the registration form contains(s) confidential information belonging to the author that is legally privileged. The information is intended only for the individual or entity named above. If you are not the tntended recipient, you are herby notifed that any disclosure, copying, distribution, or taking of any action in release of the contents of this information is strictly prohibited. If you have received this registration form in error, please notify us by telephone immediately to arrange for the return of the original documents to Baylor Medical Center at Frisco.