New Registration Form

PATIENT INFORMATION

Patient Information:

New Update

Today's Date:

Patient's Full Name:

Last Name:

First Name:

Middle Name:

Date of Birth:

Sex:

Male Female

Home Address:

City:

State:

Zip:

Phone #:

Ethnicity:

Hispanic Non-Hispanic Decline to Report

Preferred Method for Reminder Calls: (Choose one)

Phone # Cell Text # E-mail

If Phone # is selected, please specify:

If Cell Text # is selected, please specify:

If E-mail is selected, please specify:

PARENT INFORMATION: FATHER

Full Name:

Last Name:

First Name:

Date of Birth:

Social Security #:

Mailing Address:

City:

State:

Zip:

Home Phone #:

Cell Phone #:

Work Phone #:

Ext:

Email Address:

PARENT INFORMATION: MOTHER

Last Name:

First Name:

Date of Birth:

Social Security #:

Mailing Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Work Phone:

Ext:

Email Address:

PLEASE LIST NAMES OF ALL STEP PARENTS

add step parent

PLEASE LIST NAMES OF SIBLINGS

add sibling

EMERGENCY CONTACT nearest Friend or Relative not living in your household

Name:

Home Phone:

Relationship to Patient:

Work Phone:

For New Patients

How did you hear about our office?

Friend Family Member Health Care Provider Internet Phonebook

INSURANCE

Primary Insurance:

Subscriber's Last Name:

First:

Date of Birth:

Insurance Carrier:

ID#:

Group#:

Secondary Insurance:

Subscriber's Last Name:

First:

Date of Birth:

Insurance Carrier:

ID#:

Group#:

Are there any legal restrictions that would restrict the non-custodial parent from consenting to medical treatment for the child or from obtaining information about the child's medical treatment?

Yes No

If yes, please explain and provide a copy of any legal paperwork that supports this restriction:

Please attach a copy of any legal paperwork here:

Add file

Please upload a file

AUTHORIZATION FOR SPECIFIC CONFIDENTIAL COMMUNICATION

Is it okay to leave a detailed message including medical information on your voicemail?

Yes No

List Phone #:

I authorize my physician and /or administrative and clinical staff to disclose the following protected health information to:

Add another

Select the Protected Health Information to be used or disclosed to the above listed individual(s) from the list below:

Medical Care/Treatment

Billing Information

Pick Up PHI (such as prescription, billing statements, labs, etc.)

Other

If Medical Care/Treatment is selected, please state the level of information:

If other is selected, specify in detail - appointments: such as date of service, type of service, level of detail to be released, origin of information, etc.

This authorization shall be in force and effect and expires in 12 months or until it is revoked in writing. I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to the practice's Privacy Officer at: Grandville Pediatrics 2845 44th St., Ste.200 Grandville, MI 49418 understand that a revocation is not effective to the extent that my physician has relied on the use of disclosure of the protected health information or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient/Parent/Guardian Signature:

Date:

Your information will be encrypted.