Neha Dhudshia, M.D., P.A. – New Patient Registration Form

You will need to present a valid ID and your insurance card upon submission. Thank you and welcome to our office!

Patient's Personal Information
  • Gender:
    Gender:
  • Marital Status:
    Marital Status:
Emergency Contact Information
Patient's Referral Information
Insurance Status
  • Do you have medical insurance?
    Do you have medical insurance?
Primary Insurance Holder
  • Relationship to Patient:
    Relationship to Patient:
Primary Insurance Policy Info

Assignment of Benefits/Financial Agreement

I hereby give lifetime authorization for payment of insurance benefits to be made directly to Neha Dhudshia, M.D. and any assisting physicians or PAs, for services rendered. I understand that I am financially responsible for all charges not covered by my insurance company. In the event of default, I agree to pay all costs of collection, and reasonable attorney's fees. I hereby authorize this healthcare provider to release all information necessary to secure the payment of benefits. I further agree that a photocopy of this agreement shall be valid as original.

I verify the above information is correct.