Patient Registration Forms - English

Skagit Pediatrics

Please correct the errors described below.

Patient Information

Parent Information

Parent info #1

Parent info #2

Insurance Information ***** Please Give Cards to the Receptionist****

Primary Insurance

Secondary Insurance

Please list all children in the family

Add child

Consent for care and treatment

I agree to administration of medical treatment by the physicians/ARNPs of Skagit Pediatrics and their assistants for care of the above listed children. I understand these procedures will be explained to me in advance.

I hereby authorize my insurance benefits to be paid directly to the physician and I am financially responsible for non-covered services. I also authorize the release of any information required in the processing of claims.

I have read and understood the terms of this agreement. I am the proper person to give this consent.

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 agreement is void and unenforceable, and I am under no obligation to pay the provider, if my medical program covers the services listed above or if the provider fails to satisfy DSHS conditions of payment as described under WAC 388-87-010(6)

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