New Patient Form

Welcome to Caring Hands Children’s Clinic!

Please correct the errors described below.

Please list all other siblings (seen at this clinic) you want on this account:

Add new row for another sibling

Mother’s Information

Father’s Information

(not in household)

Primary Insurance

(The only insurance we file secondary is BCBS. Please give your primary and secondary card to the receptionist)

Assignment of Benefits

I hereby authorize payment directly to The Children’s Clinic, PLLC for all insurance benefits otherwise payable to me for services rendered. I certify that the information I have reported to The Children’s Clinic, PLLC with regard to my insurance is correct. I also authorize the release of any necessary information, including medical information, if requested by my insurance company. I permit a copy of this authorization to be used in such instances. I authorize the use of this signature on all insurance submissions. I understand that I am financially responsible for all charges, whether or not paid by insurance and for all services rendered on my behalf or my dependents.

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

Your information will be encrypted.