1404 Tusculum Blvd., MOB 3, Suite 3000, Greeneville, TN 37745

Mon - Fri, 7:40am - 4:30pm

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Patient Registration Initial Intake

Home Patient Registration Initial Intake

Become a New Patient

Becoming a patient at Greeneville Family Medicine is easy…we will guide you through every step of the process.

Here are few of the insurances we take.

To get started, we just need some basic information. Please complete and submit the form below.

1Step

2Step

SUMMIT MEDICAL GROUP PAITENT REGISTRATION FORM
ACCOUNT
DATE
MM slash DD slash YYYY
PHYSICIANS NAME
PATIENT'S NAME
First Middle Last
BIRTH DATE
MM slash DD slash YYYY
AGE
ADDRESS
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
SOCIAL SECURITY
HOME PHONE
MOBILE PHONE
WORK OR BUSINESS PHONE
MARITAL STATUS
SEX
EMPLOYER'S NAME AND ADDRESS
RACE
- AFRICAN AMERICAN
- ASIAN
- CAUCASIAN
- HISPANIC
- NATIVE AMERICAN
EMAIL ADDRESS
PRIMARY LANGUAGE
PHARMACY OF CHOICE
PHARMACY PHONE
HOW WERE YOU REFERRED TO SUMMIT MEDICAL GROUP ?
HAVE YOU BEEN TREATED BY A SUMMIT MEDICAL GROUP PHYSICIAN PREVIOUSLY?
- YES
- NO
DO YOU HAVE A DURABLE POWER OF ATTORNEY FOR HEALTHCARE?
- YES
- NO
DO YOU HAVE A LIVING WILL?
- YES
- NO
If yes, please provide a copy of the above documents(s) to the office for your medical record.
PERSON/GUARANTOR RESPONSIBLE FOR PAYMENT OF SERVICES (IF DIFFERENT FROM PATIENT)
NAME
First Middle Last
RELATIONSHIP TO PATIENT
ADDRESS
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
SOCIAL SECURITY
HOME PHONE
MOBILE PHONE
WORK OR BUSINESS PHONE
BIRTH DATE
MM slash DD slash YYYY
SEX
EMPLOYER'S NAME AND ADDRESS
EMERGENCY CONTACT (NOT WITHIN THE SAME HOUSEHOLD)
NAME
EMERGENCY PHONE NUMBER
RELATIONSHIP TO PATIENT
INSURANCE INFORMATION
PRIMARY INSURANCE
INSURANCE NAME
EFFECTIVE DATE
MM slash DD slash YYYY
CLAIMS ADDRESS
SUBSCRIBER ID NUMBER
GROUP NUMBER
SUBSCRIBER NAME AND ADDRESS
SUBSCRIBER BIRTHDATE
MM slash DD slash YYYY
SUBSCRIBER SS
RELATION TO PATIENT
EMPLOYER NAME, ADDRESS AND PHONE NUMBER
SECONDARY INSURANCE
INSURANCE NAME
EFFECTIVE DATE
MM slash DD slash YYYY
CLAIMS ADDRESS
SUBSCRIBER ID NUMBER
GROUP NUMBER
SUBSCRIBER NAME AND ADDRESS
SUBSCRIBER BIRTHDATE
MM slash DD slash YYYY
SUBSCRIBER SS
RELATION TO PATIENT
EMPLOYER NAME, ADDRESS AND PHONE NUMBER
FOR PRESCRIPTIONS, DO YOU USE YOUR
- PRIMARY INSURANCE
- SECONDARY INSURANCE
The Patient or Guarantor is responsible for payment in full of all services rendered by the physicians or employees of Summit Medical Group, PLLC. Payment in full is expected at the time of service unless arrangements are made in advance.
AUTHORIZATION, ASSIGNMENT, AND RESPONSIBILITY OF ACCOUNT
I thereby authorize Summit Medical Group, PLLC to release to the above insurance companies &/or carriers any medical or other information needed for claims reimbursement.
I hereby assign, transfer, and set over to Summit Medical Group, PLLC all of my rights, title, and interest to medical reimbursement benefits under my insurance policy with the above documented insurance companies. I hereby acknowledge and accept responsibility for payment in full of all services rendered to me by Summit Medical Group, PLLC.
DATE
MM slash DD slash YYYY
SIGNATURE OF PATIENT/GUARDIAN
Max. file size: 128 MB.

Call 423-638-1188 and press 4 to schedule an appointment today with an Greeneville Family Medicine primary care provider, the first step to a healthier life.

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1404 Tusculum BLVD. MOB 3, Suite 3000 Greeneville, TN 37745

423-638-1188
Mon-Fri, 7:40am-4:30pm

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© 2022 GreenevilleFamilyMedicine. All Rights Reserved.