Child Registration Form

Parent/Guardian#1:

Last name:

First name:

Middle initial:

Relationship to the patient:

Mother Father Stepmother Stepfather Other

Date of Birth:

SS#:

Email:

Home phone:

Cell phone:

Work phone:

I authorize messages that include protected health information to be left on:

Home

Cell

I authorize automated reminder calls to be left on:

Home

Cell

DO NOT LEAVE AUTOMATED REMINDER CALLS

Address: (where child/children reside)

Street:

City:

State:

Zip

Parent/Guardian#2:

Last name:

First name:

Middle initial:

Relationship to the patient:

Mother Father Stepmother Stepfather Other

Date of Birth:

SS#:

Email:

Home phone:

Cell phone:

Work phone:

I authorize messages (including PHI) to be left on

Home

Cell

DO NOT LEAVE MESSAGES

I authorize automated reminder calls to be left on

Home

Cell

DO NOT LEAVE AUTOMATED REMINDER CALLS

Address:

Same as Parent/Guardian #1 If not please list address here:

Street:

City:

State:

Zip

Please list all children:

Add children

Responsible party ( must sign financial policy) :

Same as Parent/Guardian #1

Same as Parent/Guardian #2

( If other, please complete below: )

Name:

Relationship to patient:

Date of Birth:

SS#:

Email:

Home phone:

Cell phone:

Work phone:

Street:

City:

State:

Zip:

Medical Insurance Information

Primary Insurance Name:

Subscriber/policy holder:

Employer:

Policy #:

Group Number:

Policy Effective Date:

Claims Address:

Co- Pay/deductible amount

Secondary Insurance Name:

Subscriber/policy holder:

Policy #:

Group Number:

Policy Effective Date:

Employer:

Co- Pay/deductible amount

Please answer the following questions:

I do not wish to answer

If you checked Other, please specify:

Religion:

Primary Language:

English Other I do not wish to Answer

If you checked Other, please specify:

Do your answers apply to all your children?

Yes No

Do you require any interpreter services?

Yes No

Please describe interpreter services that are required (related to communication):

Assignment & Release:

I give permission for West Side Pediatrics, or persons designated by them, to interview, examine and perform necessary laboratory procedures and to provide appropriate treatment to the above named minor. I further give my permission for evaluation and treatment whether the child is accompanied by a parent/legal guardian, other family member, unrelated party or is unaccompanied. I, the undersigned, assign directly to West Side Pediatrics all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible and have received the financial policy. I hereby authorize the use of this signature on all insurance submissions. I further authorize West Side Pediatrics to forward any information necessary, including, but not limited to medical records, to said insurance company for payment of my insurance claims as well as to other personnel to whom physicians of West Side Pediatrics have referred my child for treatment and to the admitting hospital should my child be admitted for treatment.

PLEASE NOTE: Whoever accompanies the child to each visit is expected to pay the charges due for the service rendered that day, including copayments, coinsurance, deductibles, etc. Divorce has no bearing on the responsibility for medical care as it affects third parties

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

Name:

Signature:

Relationship to patient(s):

Date:

Your information will be encrypted.