Blank Registration Forms

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.

Form #1: Member/Patient Personal Details
Form #1-A : Member/Patient Employer Information (Fill only if the Member/Patient is employed)
Form #2 : Policy Information (Policy Information of Member/Patient)
Form #2-A : Policy Holder Information (Fill only if the Member/Patient is Dependent)
Form #2-B : Policy Holder Employer Information (Fill only if Form #2-A applicable and Policy Holder is Employed)
Form #3 : Guarantor Information (A guarantor is the person responsible for payments that are not covered by insurance policy of the patient, such as 20% portion in an 80/20 type of policy)
Form #3-A : Guarantor Employer Information

P2P Member Registration Instructions

If you are in a HURRY…only fill-out required sections of all the forms so that the physician can see the patient. But, in order to complete your registration, you must fill remaining sections later within 30 days.
Register the Policy Holder and Guarantor of the patient as a P2P member. (If the patient is also the Policy Holder, then skip this step and go to step 4.)

Write –down the P2P member ID and Password for the Policy Holder/Guarantor. Then logout, and login again to fill patient (dependent) information.
Register Patient as a P2P member.
Write down the P2P member ID and Password for the patient.
Fill-out Brief Medical History form for the patient.
Select a Medical Practice from the list where the patient has an appointment.
Read and Fill-out the HIPAA forms, medical office Policy, your credit card information etc. to meet US federal government requirements, insurance company requirements, and medical office policy requirements.

Form #1

Member Personal Details (Required/Must Fill In)
Last Name:*
First Name:*
Middle Initial:
Birth Date: *
Sex:
Address:*

City:*
State:*
Zip Code:* #	With Extension
E-Mail: (Optional)
Contact Numbers - At lease one Phone number is Required
Home: #	With Extension
Cell: #
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, such as 20% portion in an 80/20 type of policy
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)
Fax Number: # (Optional)
Birth Weight: (Optional)
Marital Status: (Optional)
Social Security Number: #(Optional)
Identity: (Optional)
Retirement Date: (Optional)
Emergency Contact Name: (Optional)
Home Phone: # (Optional)
Cell Phone: # (Optional)

Form #1-A

Member/Patient Employer Information (Required / Must Fill In)
Employer Name: *
Address: *

City Name:*
State:*
Zip Code: *	With Extension
Main Phone: *
Office Contact Person: *
Office Contact Phone: *	With Extension
Other Information : (If you are in a hurry fill in later)
Fax:
Employee ID: (Optional)
Identifier: (Optional)
Email: (Optional)

Form #2

Policy Information (Required/Must Fill In)
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)


Insurance Company: *
Plan Name: (Optional)
Plan ID: (Optional)
Type: *	If you don't know, Please Enter "Commercial"
Policy Number: *
Group Number: *
Policy Start Date: *
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)
Last Name:*
First Name:*
Middle Initial:
Birth Date: *
Sex:*
Address:*

City:*
State:*
Zip Code:*	With Extension
Contact Phone Number :	With Extension
Contact Cell Number:
Other Information : (If you are in a hurry fill in later)
Work Contact Number:
Phone Other:
Fax Number:
E-Mail:
Birth Weight:
Marital Status:
Social Security Number:
Identity:
Retirement Date:
Emergency Contact Name:
Home Phone:
Cell Phone:

Form #2-B

Policy Holder's Employer Information (Required/Must Fill In)
Employer Name: *
Street: *

City Name:*
State:*
Zip Code: *
Main Phone: *
Office Contact : *
Office Contact Phone: *
Other Information : (If you are in a hurry fill in later)
Fax Number:
Employee ID:
Identifier:
Email:

Form #3

Guarantor Details (Required/Must Fill In)
Last Name:*
First Name:*
Middle Initial:
Birth Date: *
Sex:*
Address:*

City:*
State:*
Zip Code:*	With Extension
Contact Phone Number :	With Extension
Contact Cell Number:
Other Information : (If you are in a hurry fill in later)
Work Phone Number :
Phone Other:
Fax:
E-Mail:
Confirm E-Mail:
Birth Weight:
Marital Status:
Social Security Number:
Identity:
Retirement Date:
Emergency Contact Name:
Home Phone:
Cell Phone:

Form #3-A

Guarantor's Employer Information (Required/Must Fill In)
Employer Name: *
Street: *

City Name:*
State:*
Zip Code: *	With Extension
Main Phone: *
Office Contact : *
Office Contact Phone: *	With Extension
Other Information : (If you are in a hurry fill in later)
Fax:
Employee ID:
Identifier:
Email: