New Patient Registration Form

For patients who have already set up an initial appointment with me, you can fill out the New Patient Registration Form below.

You will also need to submit the HIPAA privacy policy acknowledgement form.

Download Forms

If you prefer, you may download the forms here as pdf’s and fax them to 617.232.8580 ahead of your appointment time.

New Patient Registration Form

Name(Required)

First Last

Work Phone

Cell Phone

Email(Required)

Address

Street Address City State ZIP Code

Date of Birth

Referred By?

Primary Care Physician (PCP)

PCP Phone:

MEDICAL INSURANCE INFORMATION

Insurance Company

Plan Name

Insurance Address

Street Address City State ZIP Code

Insurance Phone:

Name of Policy Holder:

Relation to patient

Policy/ID#

Group

I FULLY UNDERSTAND AND AGREE THAT HEALTH INSURANCE POLICIES ARE ARRANGEMENTS BETWEEN INSURANCE CARRIER(S) AND MYSELF. FURTHERMORE, I UNDERSTAND THAT DANIEL MOLLOD, MD., WILL PREPARE ANY NECESSARY REPORTS AND FORMS TO ASSIST ME IN MAKING COLLECTIONS FROM MY INSURANCE COMPANY AND THAT ANY AMOUNT AUTHORIZED TO BE PAID DIRECTLY TO DANIEL MOLLOD, MD., WILL BE CREDITED TO MY ACCOUNT UPON RECEIPT. I CLEARLY UNDERSTAND AND AGREE THAT ALL SERVICES RENDERED TO ME ARE MY PERSONAL RESPONSIBILITY FOR PAYMENT. I ALSO UNDERSTAND THAT WHEN RELEASED FROM CARE FOR THIS PRESENT CONDITION, ANY REMAINING FEES FOR PROFESSIONAL SERVICES ARE DUE WITHIN 30 DAYS.

I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM ONLY. I ALSO REQUEST PAYMENT OF INSURANCE BENEFITS EITHER TO MYSELF OR TO THE PARTY WHO ACCEPTS ASSIGNMENT.
I AUTHORIZE PAYMENT OF MEDICAL BENEFITS DIRECTLY TO DANIEL MOLLOD, MD., FOR SERVICES DESCRIBED.

I HAVE READ AND AGREED TO THE ABOVE AND ACKNOWLEDGE THAT THE INFORMATION GIVEN ON THESE FORMS IS TRUE.

RESPONSIBLE PARTY SIGNATURE(Required)

Date