Bicity Medical Ministries

New Patient Registration Center

For quicker office visits follow the instructions below

1) Download, Print and Complete the following Forms ( Download Forms Here )
2) Complete and print the following form.

Personal Information (All Fields Required)
First Name:		Last Name:
Middle Initial:		Responsible Party:
Street Address:		City:
State:		Zip:
Email:		Email Confirm:
User Name:		Password:
Age:		Birth Date
Marital Information (Please Select One)
Marital Status: Single: Married: Widowed: Separated: Divorced:
Employer Information ( If Applicable )
Employed By:
Business Address:
Occupation:		Business Phone:
Spouse Employer Information ( If Applicable )
Employed By:
Busines Address :
Occupation:		Business Phone:
Who's Responsible for this Account / Relationship to Patient ( If Applicable )
Repsonsible for Account:		Relationship to patient:
Social Secuity Numbers ( If Applicable )
SS Number:		Spouse SS Number:
Primary Insurer Information ( If Applicable )
Medical Insurance:	No Yes
(If Yes) Primary Insurer:		Contact Number:
Group Number:		Subscriber:
Secondary Insurer Information ( If Applicable )
Secondary Insurer: (If Any)		Contact Number:
Group Number:		Subscriber:
Medicare / Medicaid / Welfare Information (If Applicable )
Medicare:	Medicaid:	Claim Id: #
If Welfare, Your #		County Of:
Emergency Information ( All Fields Required )
Emergency Notification		Phone:
Pharmacy Information ( If Applicable )
Your Drug Store Name:		Phone:
Other Information ( Please Complete )
How did you learn of our practice: