Blank Registration Forms The P2P Network is a SECURE network and fully complies with US Federal Government's HIPAA regulations. The P2P member data (patient data, physician data etc.) cannot be accessed by anybody else without your permission. When you select a medical practice or physician, only then your data will be transferred to the selected medical office.
P2P Member Registration Instructions
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Form #1
Member Personal Details (Required/Must Fill In) |
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Last Name:* |
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First Name:* |
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Middle Initial: |
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Birth Date: * |
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Sex: |
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Address:* |
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City:* |
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State:* |
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Zip Code:* # |
With Extension |
E-Mail: (Optional) |
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Contact Numbers - At lease one Phone number is Required | |
Home: # |
With Extension |
Cell: # |
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Mode of Payment: * |
Self Pay Insurance
Policy
If "Self" do not fill Form #2, #2-A, #2-B |
Is Member Employed * |
Yes No (If "Yes" please fill Form #1-A) |
Specify guarantor for Member * | Self Not Self |
A guarantor is
the person responsible for payments that are not covered by insurance
policy of the patient, |
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Forgot Password Question: * | |
Type Secret Question * | |
Type Answer * | |
Other Information : (If you are in a hurry fill in later) | |
Contact Work:# (Optional) |
With Extension |
Other Contact Number: # (Optional) |
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Fax Number: # (Optional) |
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Birth Weight: (Optional) |
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Marital Status: (Optional) |
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Social Security Number: #(Optional) |
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Identity: (Optional) |
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Retirement Date: (Optional) |
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Emergency Contact Name: (Optional) |
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Home Phone: # (Optional) |
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Cell Phone: # (Optional) |
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Member/Patient Employer Information (Required / Must Fill In) |
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Employer Name: * |
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Address: * |
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City Name:* | ||
State:* |
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Zip Code: * |
With Extension |
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Main Phone: * |
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Office Contact Person: * |
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Office Contact Phone: * |
With Extension |
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Other Information : (If you are in a hurry fill in later) | ||
Fax: |
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Employee ID: (Optional) |
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Identifier: (Optional) |
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Email: (Optional) |
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Form #2
Policy Information (Required/Must Fill In) |
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If your insurance card has more than one company name written on it, please call the insurance company and ask them which name should be used for submitting Electronic Claims (or paper claims if your insurance company does not accept electronic claims) |
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Insurance Company: * |
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Plan Name: (Optional) |
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Plan ID: (Optional) |
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Type: * |
If you don't know, Please Enter
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Policy Number: * |
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Group Number: * |
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Policy Start Date: * |
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Policy End Date: * |
If your insurance card does not show any end date, please enter any future date (i.e. 12/31/2010) |
Capitated Plan: * |
Yes No |
Relation to Policy Holder * |
("If this is the
information about the policy holder, please select "self" and
do not fill
Form # 2-A, #2-B) |
Annual Deductible: * | |
Co-Payment Amount: * | |
Insurance Coverage %: * | % |
Insurance Payment Authorization |
I hereby authorize any medical practice who is a member of the P2P network, to apply for benefits on my behalf for services rendered to me or my dependents, and request that payment be made by my current insurance company, and that payment be sent directly to the P2P member medical practice. I understand that this authorization in no way relieves me of my primary responsibility to pay for services rendered to me, or my dependents, including the services not covered by my insurance plan. In case my insurance company denies the payment for any reason whatsoever including incorrect information given to the medical practice by me, my family member, or my representative), or does not pay the full amount, or my dependents and I are not covered by any insurance policy on the day of receiving medical services, I agree to pay the full/balance amount. If I fail to make the payments, and my account is turned over to an attorney for collection, I agree to pay any reasonable legal and collection fees, court costs, and other expenses incurred as a result of said collection. For outstanding balances more than 30 days, I also agree to pay a finance charge of 1.5% per month. In case I request a medical practice to transfer my medical records to a non-P2P-member medical organization, I agree to pay a reasonable Records Transfer Fee as determined by the medical practice. I certify that the information I have reported with regards to my insurance coverage is correct, and I authorize the release of my information relating to any claim for benefits, in order to process the claim. Furthermore, I permit a copy of this authorization to be used in place of the original. I may revoke this authorization at any time in writing. I authorize P2P Network staff to make corrections on my behalf, if I made any mistakes in entering my information in P2P registration forms. |
Date : |
Signature |
Form #2-A
Policy Holder Details (Required/Must Fill In) |
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Last Name:* |
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First Name:* |
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Middle Initial: |
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Birth Date: * |
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Sex:* |
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Address:* |
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City:* |
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State:* |
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Zip Code:* |
With Extension |
Contact Phone Number : |
With Extension |
Contact Cell Number: |
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Other Information : (If you are in a hurry fill in later) | |
Work Contact Number: |
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Phone Other: |
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Fax Number: |
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E-Mail: |
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Birth Weight: |
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Marital Status: |
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Social Security Number: |
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Identity: |
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Retirement Date: |
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Emergency Contact Name: |
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Home Phone: |
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Cell Phone: |
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Form #2-B
Policy Holder's Employer Information (Required/Must Fill In) |
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Employer Name: * |
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Street: * |
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City Name:* | ||
State:* |
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Zip Code: * |
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Main Phone: * |
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Office Contact : * |
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Office Contact Phone: * |
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Other Information : (If you are in a hurry fill in later) | ||
Fax Number: |
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Employee ID: |
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Identifier: |
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Email: |
Form #3
Guarantor Details (Required/Must Fill In) |
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Last Name:* |
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First Name:* |
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Middle Initial: |
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Birth Date: * |
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Sex:* |
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Address:* |
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City:* |
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State:* |
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Zip Code:* |
With Extension |
Contact Phone Number : |
With Extension |
Contact Cell Number: |
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Other Information : (If you are in a hurry fill in later) | |
Work Phone Number : |
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Phone Other: |
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Fax: |
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E-Mail: |
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Confirm E-Mail: |
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Birth Weight: |
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Marital Status: |
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Social Security Number: |
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Identity: |
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Retirement Date: |
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Emergency Contact Name: |
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Home Phone: |
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Cell Phone: |
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Form #3-A
Guarantor's Employer Information (Required/Must Fill In) |
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Employer Name: * |
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Street: * |
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City Name:* | ||
State:* |
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Zip Code: * |
With Extension |
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Main Phone: * |
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Office Contact : * |
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Office Contact Phone: * |
With Extension |
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Other Information : (If you are in a hurry fill in later) | ||
Fax: |
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Employee ID: |
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Identifier: |
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Email: |