Melissa Selke MD

Financial Policy

Transfer Medical Records

Hippa Notice of Privacy Practices

Hours
by appt only

M - 9-5pm
T - 9-7:30pm
W - Emergency
appts only
Th - 9-5pm
F - 9-4pm
S - Select dates
only

Nutrition

General Health
- Noah Health
- Family Doctor

Children's Health
- Kid's Health
- CDC

Drug Assistance
Programs/Medicare Part D
- RxAssist
- NeedyMeds

Version: 1.0

Patient Registration

Complete form to register yourself as a patient.

Patient Information

Name :
Address :
Home Phone :
Cell Phone :
DOB :	- -
Gender :	male female
Marital Status :	Single Married Widowed Divorced
Occupation :
Employer :
Work Phone :

Insurance Information

Please check if no insurance coverage. Skip to purple section.

Primary Policy	(Name of Insured)
Policy Holder :
DOB :	- -
Company :
Policy # :
Address :
City :
State :
Zip :

Scndry. Policy	(Major Medical)
Company :
Policy #
Address :
City :
State :
Zip :
Phone #


Who is responsible for payment? (Owner of Insurance)

	Please check if self. then continue to green section.

Name :		Home #
Address :
Employer :		Work #
Address :
City :
State :
Zip :

In case of emergency, who should be notified?

Name :
Relationship :
Phone :

Name :
Relationship :
Phone :

Preferred Pharmacy :
Phone #
Allergies to Medications :