New Patient Registration Form

Patient Name

Sex

Male Female

DOB

Name you call your child

Father's Name

Date of Birth

S.S.#

Employer

Occupation

Emp. Address

Emp.Phone

City

State

Zip Code

PGR/Cell#

Home Address

Home Phone #

City

County

State

Zip Code

Mother's Name

Date of Birth

S.S.#

Employer

Occupation

Employee Address

Emp.Phone

City

State

Zip Code

PGR/Cell#

Home Address

Home Phone

City

State

Zip Code

Email Address

IN CASE OF EMERGENCY PLEASE CONTACT (someone other than parent)

Name

Relationship

Phone

INSURANCE INFORMATION

1. Insurance Company

Group#

Insured's Name

I.D.#

Date of Birth

Is this ins. through your employer?

2. Insurance Company

Group#

Insured's Name

I.D.#

Date of Birth

Is this ins. through your employer?

I HEREBY AUTHORIZE PAYMENT DIRECTLY TO PEDIATRIC HEALTH CENTER OF ALL SURGICAL AND/OR MEDICAL BENEFITS, IF ANY, FOR HIS SERVICES PROVIDED FOR MY CHILD WHICH YOUR OFFICE MAY FILE ON MY BEHALF. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR THE CHARGES NOT COVERED BY THIS AUTHORIZATION. I UNDERSTAND THAT IF A BALANCE ON THIS ACCOUNT IS UNPAID AFTER THIRTY (30) DAYS ON OFFICE VISITS OR SIXTY (60) DAYS ON HOSPITAL CHARGES, I AM RESPONSIBLE FOR ALL COLLECTION FEES INCURRED IN ORDER TO COLLECT THE BALANCE. ALL OFFICE VISITS AND SERVICES ARE DUE AND PAYABLE AT TIME OF SERVICE, UNLESS, OTHER ARRANGEMENTS HAVE BEEN MADE PRIOR TO YOUR VISIT. I UNDERSTAND THAT ALL CONTRACTED INSURANCE CLAIMS WILL BE FILED, BUT THE GUARANTOR IS ULTIMATELY RESPONSIBLE FOR ALL FEES INCURRED. I HEREBY AUTHORIZE RELEASE OF ANY RECORDS/ INFO FROM PREVIOUS AND REF HOSPITALS/PROVIDERS TO PHC NECESSARY FOR MEDICAL TREATMENT OR TO PROCESS ANY CLAIMS FILED ON MY CHILD’S BEHALF.

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.

Signature

Date

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