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You are on your way.

A member of our care team will contact you within one business day to confirm your appointment and send you a link to complete your full patient registration through our secure patient portal. Questions in the meantime? Call us at 334-321-0060.

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Step 1 of 6 · About You

Step 1 of 6

About You

Basic information so we can create your record. Fill in what you have. Anything missing can be completed at your first visit.

Legal Name

Last Name

First Name

Middle Initial

Identity

Date of Birth

Last 4 of SSN

Gender

Marital Status

Home Address

Street Address

City

State

Zip

Contact

Cell Phone

Home Phone

Employer

Work Number

OK to contact at work?

Emergency Contact

Full Name

Relationship

Primary Phone

Alternate Phone

How did you hear about us?

Back

Step 2 of 6

Guarantor

Only complete this if the patient is a dependent, a minor child or someone covered under another person's account. If the patient handles their own account, skip ahead.

Guarantor Name

Relation to Patient

Last Name

First Name

Middle Initial

Guarantor Identity

Date of Birth

Last 4 of SSN

Gender

Employer

Guarantor Address & Contact

Street Address

City

State

Zip

Home Phone

Cell Phone

Work Number

OK to contact at work?

Step 3 of 6

Insurance

Have your insurance card handy. Co-pays and balances are due at time of service. We do not accept personal checks.

Assignment of Benefits: I authorize payment of insurance benefits directly to East Alabama Primary Care. I understand I am responsible for charges not covered by my plan, including co-pays, deductibles, and non-covered services.

Primary Insurance

Insurance Plan Name

Policy / ID #

Group #

Effective Date

Policy Holder Name

Policy Holder DOB

Holder's Relationship to Patient

Secondary Insurance (if applicable)

Insurance Plan Name

Policy / ID #

Group #

Effective Date

Policy Holder Name

Policy Holder DOB

Holder's Relationship to Patient

Step 4 of 6

Preferred Pharmacy

Where we send your prescriptions. Your care team will review your medications and any allergies with you at your first visit.

Preferred Pharmacy

Pharmacy Name

Pharmacy Phone

Address

Secondary Pharmacy (optional)

Pharmacy Name

Pharmacy Phone

Address

Step 5 of 6

Information Release

Name up to two people our staff may speak with regarding your medical condition, test results, appointments, and billing.

Authorized Person #1

Full Name

Relationship to You

Phone

Authorized Person #2 (optional)

Full Name

Relationship to You

Phone

Your Signature

Type Full Legal Name

If signing for a dependent, your relationship

Step 6 of 6

Consent & Policies

Review and sign the required agreements to complete your registration.

Patient Consent, HIPAA

Print Full Name

Signature (type full name)

If signing for a dependent, your relationship

Notice of Privacy Practices

Print Full Name

Signature (type full name)

Office & Financial Policies