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Available Forms

A.) Patient Registration

Patient Registration

Please include Pharmacy name, address, phone number and zip code.

Insurance Information

Emergency Contact Information


The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Rittenhouse Internal Medicine, P.C. or insurance company to release any information required to process my claims. If Medicare is my only insurance carrier, I understand that I am fully responsible for my 20% co-insurance due after Medicare payment.

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