New Patient Information Portal

Sherry Nussbaum, M.D., P.A.
1008 North Bowen Road
Arlington, TX 76012
(817) 861-2288
www.sherrynussbaummd.com

Patient Registration

Today's Date: * +

Patient Information

SSN: 🛈

Sex: *

Date of Birth: *

First Name: *

Middle Initial:

Last Name: *

Street Address *

Address Line 2

City *

State *

Zip Code *

Pharmacy name and number *

Insurance Information

Zip Code *

Phone Number *

Privately Insured (BCBS, UHC, Aetna, Etc.)

Amerigroup

Uninsured

Other Other

We apologize but we are unable to accept Cook Childrens STAR program or any program with state Medicaid including: Traditional MDCD, TMHP, or other Medicaid subprograms of AETNA, UHC and other private insurance companies. *

Insurance Provider:

Insurance Subscriber's Full Name:

Subscriber's Relationship to Patient:

Member ID:

Group Number:

Subscriber's Date of Birth:

Subscriber's SSN: 🛈

Insurance Claims Address: * 🛈

Parent/Guardian #1 Information

Parent SSN: 🛈

First Name *

Last Name *

Guarantor Relationship to Patient: *

Mother

Father

Legal Guardian

Other Other

Street Address *

Address Line 2

City *

State *

Zip Code *

Home Phone Number *

Email: * 🛈

Mobile Phone Number

Work Phone Number

Parent/Guardian #2

If you wish to add a second parent/guardian, please fill out the following information.
Otherwise, skip down to Emergency Contact Information.

Parent SSN 🛈

First Name

Last Name

Guarantor Relationship to Patient:

Mother

Father

Legal Guardian

Other Other

Street Address

Address Line 2

City

State

Zip Code

Home Phone Number

Mobile Phone Number

Work Phone Number

Emergency Contact

If you wish to add an Emergency Contact, please fill out the following information.
Otherwise, proceed to the next page.

First Name:

Last Name:

Emergency Contact Relationship to Patient:

Home Phone Number

Mobile Phone Number

Documents

If you have access to a scanner, you may scan a copy of your ID and upload it here.

If you have access to a scanner, you may scan a copy of your insurance card and upload it here.

If you have access to a scanner, you may scan a copy of your shot record and upload it here.

Authorization

AUTHORIZATION TO PAY BENEFITS TO PHYSICIAN: I hereby authorize payment directly to the physician of the surgical and/or medical benefits, if any, otherwise payable to me for his/her services as described, realizing I am responsible to pay non-covered services.

AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize the physician to release any information acquired in the course of my treatment necessary to process insurance claims.

*

By checking this box, I agree to the Terms and Conditions listed above. I also agree that all information listed above is correct.

E-Signature- Please type your full name below: *

Today's Date: * +