Webster Square Medical Center

 
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Webster Square Medical Center

255 Park Ave., Suite 400

Worcester, MA 01609

508-755-9776

508-831-7861 (Fax) 
Forms:

Select form and print.  To save time in the waiting room bring your completed Registration Form.  An updated Registration Form is required once a year.

                                                       REGISTRATION FORM

                                    WEBSTER SQUARE MEDICAL CENTER, INC.

PLEASE PRINT ALL INFORMATION BELOW
PART 1 - PATIENT INFORMATION
NAME:
STREET:
CITY:                                                           STATE:                                    ZIP:
SOCIAL SECURITY #:
HOME PHONE:                                         BUSINESS PHONE:                                             CELL:
DATE OF BIRTH:                                      MARITAL STATUS:                       
EMERGENCY CONTACT:                                                     PHONE#:
FINANCIALLY RESPONSIBLE PARTY:
ADDRESS:                                                                              PHONE #:
PART 2 - EMPLOYER INFORMATION
NAME OF EMPLOYER:
ADDRESS:
CITY:                                                            STATE:                                   ZIP:
PHONE#:                                                      JOB TITLE:
PART 3 - INSURANCE INFORMATION
PRIMARY POLICY #:                                                             GROUP#:
SUBSCRIBER:                                                                         SS #:
SECONDARY POLICY #:                                                       GROUP#:
SUBSCRIBER:                                                                         SS #:
PART 4 - STUDENTS
SCHOOL NAME:                                                                      PHONE #:
HOME ADDRESS: ( If different from above )
STREET:                                                          CITY:                          STATE:            ZIP:
HOME PHONE:
                   FINANCIAL INFORMATION - GENERAL CONSENT FOR TREATMENT - CONSENT TO RELEASE /USE
                               MEDICAL INFORMATION AND AUTHORIZATION TO PAY INSURANCE BENEFITS
This information is accurate and true to the best of my knowledge. I understand that I am responsible to pay for services rendered, to include all expenses collected
for collection fees and reasonable attorney's fees in the event of default should Webster Square Medical Center, Inc. institute action for the enforcement of collection
of the account upon which this form is based. Attorney's fees will be added and made part of your medical bill prior to being sent over for collection to the attorney.
Said attorney's fees shall be added in the amount of 40% which both parties agree to be reasonable.
I hereby give Webster Square Medical Center, Inc my consent for any necessary evaluation and / or treatment.
I authorize the release of any information that may be required by my insurance company, their reimbursing agency, or as may be otherwise necessary for payment
of claims resulting from my medical care and /or treatment.
I understand that this information will be disclosed for billing and utilization review purposes. This may include information in my file which concerns HIV, AIDS,
mental illness, sexually transmitted diseases, drug/alcohol, termination of pregnancy, and/or domestic violence.
X
Signature of Patient / Parent or Legal Guardian                                             Date
                                                                                                           INITIALS _