Patient Registration

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Patient First Name

Authorized Representative or Legal Guardian First Name

Patient Last Name

Cell Phone

Patient Birthday

Authorized Representative or Legal Guardian Last Name

Do you have a healthcare insurance?

Yes

No. I attest that I do not have an individual or employer-sponsored insurance plan, I am not a member of a federal healthcare program, or the Federal Employees Health Benefits Program; and further warrant that I do not have any health care coverage.

What is your healthcare insurance carrier name?

Group Number (if no group number please type none)

Policy Number/ Member ID

Your Signature

Upload front and back of your insurance card and ID

Upload File

I declare that the info I’ve provided is accurate & complete. I authorize Rapid Response Physicians and its associates to contact me for any additional information.

Thank you for submitting! You should receive a patient portal link labeled HFA Alert via email shortly.