Patient Registration Form

Mt. Airy Pediatrics, P.C.

Please correct the errors described below.

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

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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!

Parent/Legal Guardian

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(If Applicable) Non-custodial Caretaker

(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

Secondary Health Insurance Coverage

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.

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

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