Georgia Kidney Associates

Edward D. Himot, MD., Indira Chervu, M.D., F.A.C.P., Akin O. Ogundipe, M.D., F.A.C.P., Vijay Nath, M.D.,
Sandeep Jaglan, M.D., Kimone James, M.D., Samuel A. Johnson, M.D., Samantha Suthar, M.D.

Patient Registration Form
First Name:

Last Name:

M/F (Sex): Date:
Home Address: City:
State: Zip:
Home Phone: Date of Birth: Age:
Marital Status: Social Security
Number:
Known Allergies:
Patient's Employer: Phone Number:
Address: City:
State: Zip:
Spouse's or
Parents Name:
Social Security
Number:
Spouse's or
Parents Employer:
Phone Number:
Address: City:
State: Zip:
Next of Kin/Nearest
Relative or Friend:
Phone Number:
Address: City:
State: Zip:
*** Insurance Information ***
Medicare Number: Medicade:
Insurance Company #1: Group Name:
Address: City:
State: Zip:
Insured: I.D. Number: Policy Number
Insurance Company #2: Group Name:
Address: City:
State: Zip:
Insured: I.D. Number: Policy Number
Referred By:

I authorize any physician, hospital, or clinic to provide full details of my medical history and treatment to Dr. Himot, Dr. Chervu, Dr. Ogundipe, Dr. Nath, Dr. Jaglan, Dr. James, or Dr. Johnson. I also authorize Dr. Himot, Dr. Chervu, Dr. Ogundipe, Dr. Nath, Dr. Jaglan, Dr. James, Dr. Johnson or Dr. Suthar to furnish my insurance company any information they request concerning my present illness or injury.

I authorize Georgia Kidney Associates, Edward D. Himot, MD; Indira Chervu, MD; Akin O. Ogundipe, MD; Vijay Nath, MD; Sandeep Jaglan, MD; Kimone James, MD; Samuel A. Johnson, MD; Samantha D. Suthar, MD; Renee Figueroa, ANP-BC; Trang Nguyen, NP-C; ACCNS-AG, NP-C; Alexandra Diluzio, PA-C; Angela Berndt, ACNP-BC; Jessica Brown, NP-C; and any other affiliated professionals to render medical care and treatment to me.

I hereby assign payment directly to GEORGIA KIDNEY ASSOCIATES, INC., the amount now due for medical expenses incurred and payable under terms of my basic insurance as well as Major Medical benefits. I understand that I am financially responsible for any charges not covered by this assignment. PHOTOCOPIES OF THIS FORM WILL BE INVALID.

Date: Signature of
Patient/Parent: