Patient Registration Form

We CANNOT accept this form unless you fill out both pages as completely and thoroughly as possible.

Patient Name: Last

First:

MI:

DOB:

SS#:

Sex:

Add new row for another patient

ADDRESS:

City:

State:

Zip:

Phone #:

Please share information about your race, ethnicity and preferred language with us. The Center for Medicare and Medicaid Services requires that we keep this information on file. Thank you!

RACE (Please select all that apply):

American Indian or Alaska Native

Asian American

Black or African American

Hispanic or Latino

Native Hawaiian or Other Pacific Islander

White

Multiracial

Other

If other, please specify:

ETHNICITY:

Central American

Cuban

Dominican

Hispanic or Latino

NOT Hispanic or Latino

Mexican

Puerto Rican

Spaniard

Other

If other, please specify:

PREFERRED LANGUAGE (Please select all that apply):

English

Spanish

French

Portuguese

Chinese

Hebrew

Other

If other, please specify:

If you would prefer NOT to provide us with this information, please initial here:

Parent/Legal Guardian

NAME:

Relationship to child:

Birthdate:

SS#:

Address:

City:

State:

Zip:

Phone#:

Email address:

Employer:

Work Phone#:

Cell#:

Add new row for another parent/legal guardian

(If Applicable) Non-custodial Caretaker

NAME:

Relationship to child:

Birthdate:

SS#:

Address:

City:

State:

Zip:

Phone#:

Email address:

Employer:

Work Phone#:

Cell#:

IN CASE OF EMERGENCY CALL:

Relationship:

Phone#:

Name:

Relationship:

Phone#:

Nearest relative not living with you:

Phone#:

Pharmacy Name:

Phone Number:

Pharmacy location:

(Unless you specify otherwise when you call, this is the number we will use if we ever need to call in a prescription. It is your responsibility to update this information with us.)

INSURANCE INFORMATION

Please make sure to provide the office staff with a copy of both sides of your health insurance card. It is your responsibility to advise us of any changes in your insurance coverage (including co-pay changes) as soon as they occur, in order for the billing process to go as smoothly as possible.

Primary Health Insurance Coverage

INSURANCE Co. Name:

Insurance Co. Address:

City:

State:

Zip:

Tel#:

ID#:

Group#:

Co-pay:

Subscriber Name:

Subscriber’s birthdate:

Subscriber SS#:

Subscriber’s Relationship to child:

Is child covered?

Yes No

Address:

City:

State:

Zip:

Home Phone#:

Work Phone#:

Cell#:

Secondary Health Insurance Coverage

INSURANCE Co. Name:

Insurance Co. Address:

Tel#:

ID#:

Group #:

Co-pay:

Subscriber Name:

Subscriber’s birthdate:

Subscriber SS#:

Subscriber’s Relationship to child:

Is child covered?

Yes No

Address:

City:

State:

Zip:

Home Phone#:

Work Phone#:

Cell#:

In order to control our billing costs, payment is expected when services are rendered.

I hereby authorize release of information necessary to file a claim with my insurance company and assign benefits to Mt. Airy Pediatrics. I understand that I am financially responsible for any balance not covered by my insurance carrier. A copy of this signature is as valid as the original.

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.

Signature:

Date:

This form MUST signed and it is your responsibility to update your information with us as soon as it changes.

Your information will be encrypted.